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INFANT   FEEDING 


BY 

CLIFFORD  G.  GRULEE.  A.  M.,  M.  D. 

ASSISTANT  PROFESSOR  CP  PEDIATRICS  AT  RUSH  MBDICAL  COLLEGE 
(in  AFFILIATION  WITH  THE  UNIVERSITY  OP  CHICAGO);  CHIEF  OF 
PEDIATRIC  STAFF,  COOK  COUNTV  HOSPITAL;  ATTENDING  PEDIATRICIAN 
TO  COOK  COUNTY,  PROVIDENT,  AND  ST.  BEKNARD's  HOSPITALS,  AND  TO 
THE  HOME  FOR  DESTITUTE  CRIPPLED  CHILDREN.  CHICAGO  ;  ASSOCIATE 
PEDIATRICIAN      TO     THE     PRESBYTERIAN     HOSPITAL,      CHICAGO 


ILLUSTRATED 


SECOND  EDITION.  THOROUGHLY  REVISED 


PHILADFXPHIA  AND  LONDON 

W.    B.    SAUNDERS    COMPANY 

1914 


Copyright,  1912,  by   W.   B.    Saunders   Company.     Reprinted   December, 
1912.      Revised,  reprinted,  and  recopyrighted  April,  1914 


Copyright,  1914,  by  W.    B.  Saunders  Company 


] 


PRINTED    IN    AMERICA 

PRESS    OF 

W.     B.     SAUNDERS     COMPANY 

PHILADELPHIA 


?  PREFACE  TO  SECOND  EDITION 


The  author  wishes  to  acknowledge  the  kind  way  in  which 
the  profession  has  received  the  first  edition  of  this  book. 
He  has  profited  much  by  suggestions  and  criticisms  as 
expressed  in  the  various  reviews,  and  has  endeavored  to 
correct  many  errors  in  the  text. 

This  edition  has.  been  revised  especially  from  the  scien- 
tific facts  w^hich  the  last  two  years  have  brought  forth. 
In  that  time  nothing  has  been  presented  which  would 
revolutionize  our  ideas  on  the  subject  of  infant  feeding, 
but  there  has  been  a  gradual  accumulation  of  scientific 
data  which  has  added  materially  to  our  knowledge.  It  has 
been  the  author's  wish  to  embody  such  in  the  second  edi- 
tion, and  this  has  been  done  so  far  as  possible  without 
disturbing  the  text  of  the  former  edition. 

In  presenting  this  volume  the  author  begs  to  express  a 
hope  that  it  may  be  met  with  the  same  spirit  of  friendly 
criticism  as  w^as  its  predecessor. 

Clifford  G.  Grulee. 
Chicago,  III., 
April,  1914. 


PREFACE 


Ix  preparing  this  small  volume  the  writer  has  en- 
deavored to  do  two  things:  first,  to  bring  our  knowledge 
of  the  scientific  processes  which  underlie  infant  feeding 
up  to  the  present,  and,  second,  to  put  forth  the  practi- 
cal application  of  these  principles  in  such  a  way  that 
they  can  be  grasped  by  one  no  more  famiUar  with  the 
subject  than  the  practising  physician.  In  doing  this 
he  has  met  with  many  diflSculties  and  doubtless  has 
fallen  far  short  of  his  original  intentions,  but  he  trusts 
that  the  suggestions  here  made  wiW  be  found  to  be  sim- 
ple and  yet  conform  to  scientific  principles.  To  one  who 
is  familiar  with  the  general  trend  of  pediatric  thought  in 
America  these  views  may  seem  somewhat  at  variance 
with  the  opinions  held  by  some  of  the  leading  American 
writers  on  the  subject,  but  the  views  herein  expressed 
not  only  are  substantiated  by  the  personal  observations 
of  the  writer,  but  are  confirmed  by  the  experience  of 
the  leading  Continental  physicians. 

The  book  is  based  on  a  course  of  lectures  given  to 
the  students  of  Rush  Medical  College  for  the  past  three 
years,  and  it  is  partly  due  to  the  demand  of  these  stu- 
dents that  the  present  treatise  has  been  written. 

The    writings  of   Finkelstein   and  the  book    "  Emah- 


10  PREFACE 

rung,  Ernahrangsstorungen  und  Ernahrungstherapie  des 
Kindes,"  by  Czerny  and  Keller,  have  been  freely  con- 
sulted. The  chapters  on  Physiology  of  the  Gastro-intes- 
tinal  Tract  and  Absorption  and  MetaboHsm  have  been 
written  with  free  reference  to  the  following  writers; 
Meyer,  "  Emahrungsstomngen  und  Salzstoffwechsel  beim 
Saiigling-Ergeb.  d.  inn.  Med.  u.  Kinderheilk.,"  1908,  i, 
317;  Uffenheimer,  "  Physiologie  des  Magen-Darmkanales 
beim  Saiigling  und  alteren  Kind.,"  ibid.,  1908,  ii,  271; 
Orgler,  "Der  Eiweissstoffwechsel  des  Saiiglings,"  ibid., 
1908,  ii,  464;  Freund,  "  Physiologie  und  Pathologic  des 
Fettstoffwechsels  im  Kindesalter,"  ibid.,  iii,  139. 

In  the  discussion  of  milk.  Bulletin  41  of  the  Hygienic 
Laboratory  Reports  of  the  U.  S.  Department  of  Agricul- 
ture has  been  freely  consulted. 

The  classification  of  nutritional  disturbances,  though 
in  the  main  that  of  Finkelstein,  differs  from  the  original 
in  that  the  weight  disturbance  is  somewhat  more  defi- 
nitely defined,  while  decomposition  covers  a  somewhat 
broader  field. 

The  writer  wishes  to  express  his  gratitude  to  Prof. 
Dr.  Clemens  von  Pirquet  for  permission  to  publish  the 
charts  portraying  the  nature  and  causes  of  nutritional 
disturbances,  and  Dr.  Wm.  J.  Brady  for  that  on  the  de- 
velopment of  the  teeth.  He  is  also  indebted  to  Dr.  J. 
B.  Sedgwick,  of  Minneapolis,  and  to  Drs.  A.  H.  Curtis 
and  E.  C.  Riebel,  of  Chicago,  for  reviewing  the  text,  and 
to  his  interne  at  the  Cook  County  Hospital,  Dr.  E.  B. 
Fowler,  for  taking  many  photographs. 

The  authorities  and  nurses  at  Cook  County  and  Provi- 
dent Hospitals  have  co-operated  in  various  ways.     The 


PREFACE  11 

artist,  Mr,  A.  B.  Strccdain,  and  his  stenographer,  Miss 
Lane,  have  helped  in  many  ways.  He  wishes  to  ex- 
press his  obhgation  to  his  wife  for  much  friendly  criti- 
cism, and  to  the  publishers  for  their  many  courtesies. 

CLIFFORD  G.  GRULEE. 

Chicago,  III., 


CONTENTS 


PART   L— FUNDAMENTAL    PRINCIPLES    OF 
INFANTS'    NUTRITION 

CHAPTER   I  p^QB 

Introduction 17 

CHAPTER  II 

Special  Points  in  the  Anatomy  of  the  Gastro-intestinal 

Tract  of  the  Infant 21 

CHAPTER  III 
Physiology  op  the  Gastro-intestinal  Tract  in  the  Infant.  .     27 

CHAPTER  IV 
Absorption  and  Metabolism 36 

CHAPTER  V 

Bacteriology  of  the  Gastro-intestinal  Tract  of  the  Healthy 
Infant 53 

CHAPTER   VI 

Attributes  op  the  Normal  Child 60 


PART  II.— NOURISHMENT    OF   THE   INFANT   ON 
THE    BREAST 

CHAPTER  VII 

The  Human  Breast  and  Breast-milk 72 

13 


14  CONTENTS 

CHAPTER  VIII  PAGE 

Technic  of  Breast  Nursing  of  the  Normal  Infant 88 

CHAPTER  IX 

Nutritional  Disturbances  in  the  Breast-fed  Infant 97 


PART  III.— ARTIFICIAL    FEEDING 

CHAPTER  X 
Foods  Used  in  Artificial  Feeding 116 

CHAPTER  XI 
Artificial  Feeding  for  the  Normal  Infant 141 

CHAPTER  XII 

General  Consideration  of  Nutritional  Disturbances  of  the 

Artificially  Fed  Infant 156 

CHAPTER  XIII 
Weight  Disturbance 168 

CHAPTER  XIV 
Dyspepsia 178 

CHAPTER  XV 
Decomposition 190 

CHAPTER  XVI 
Ii^oxication 208 

CHAPTER  XVII 

Symptoms  and  Their  Causes 234 


PART  IV.— NUTRITION    IN   OTHER  CONDITIONS 

CHAPTER  XVIII 
The  Premature  Infant 246 


CONTENTS  15 

CHAPTER  XIX  P^oE 

The  Exudative  Diathesis 251 

CHAPTER  XX 
The  Spasmophilic  Diathesis 259 

CHAPTER  XXI 
The  Nervous  Infant 265 

CHAPTER  XXII 

Infant  Feeding  in  Rickets 268 

CHAPTER  XXIII 
Infantile  Scurvy 273 

CHAPTER  XXIV 

Infant  Feeding  in  Eczema 275 

CHAPTER  XXV 

Congenital  Pyloric  Stenosis  and  Pylorospasm 279 

CHAPTER  XXVI 

Infant  Feeding  in  Other  Diseases 288 

Index 295 


INFANT  FEEDING 


PART   I 


FUNDAMENTAL    PRINCIPLES    OF    INFANTS' 
NUTRITION 


CHAPTER  I 
INTRODUCTION 


The  systematic  attempt  to  place  the  nourishment  of  the 
infant  upon  a  truly  scientific  basis  was  first  begun  by 
Czemy  and  Keller  when  they  published  their  epoch-mak- 
ing book  in  1905.  Previous  to  the  appearance  of  this 
volume,  though  much  scientific  and  practical  work  had  been 
done  on  the  nutrition  of  the  infant,  it  was  all  more  or  less 
fragmentary^,  and  there  had  been  no  extended  attempt  to 
separate  the  good  from  the  bad. 

When  one  remembers  that  approximately  one-fourth 
of  all  deaths  occur  in  the  first  year  of  life,  and  that  of  these 
about  60  per  cent,  are  due  to  gastro-intestinal  disturbances, 
he  begins  to  realize  how  very  important  the  proper  nutri- 
tion of  the  infant  becomes.  There  is  but  little  question 
that  of  the  other  40  per  cent,  of  those  young  infants  who 
die  from  other  causes,  many  could  be  saved  if  gastro-in- 

2  17 


18  INFANT   FEEDING 

testinal  complications  could  be  avoided.  When  these  ap- 
palling facts  confront  us,  our  duty  as  physicians  spurs  us 
to  greater  efforts  to  attain  such  knowledge  as  will  help  to 
save  the  little  ones  entrusted  to  our  care. 

As  in  all  branches  of  medicine,  the  practice  of  pediatrics, 
in  so  far  as  it  relates  to  infant  feeding,  must  vary  accord- 
ing to  the  materials  at  hand.  Any  hard-and-fast  rules 
which  presuppose  the  possession  of  apparatus  or  chemical 
substances  which  cannot  be  procured  by  any  physician, 
reduce  the  influence  of  these  principles  in  just  so  much  as 
these  are  unattainable.  In  this  way  the  most  simple  laws 
are  the  best,  provided  that  the  end  may  be  attained,  i.  e., 
the  health  of  the  child. 

In  the  practice  of  no  other  branch  of  medicine  is  it  so 
necessary  that  the  physician  in  charge  have  the  complete 
confidence  and  co-operation  of  the  patients'  attendants, 
since  patience  and  care  are  the  two  things  absolutely  neces- 
sary if  we  wish  to  get  the  best  results.  Attention  to  detaU 
over  many  weeks  is  frequently  necessary  to  preserve  the 
lives  of  our  small  patients,  and  a  clear  judgment,  exercised 
constantly,  with  a  proper  estimate  of  the  time  and  trouble 
involved,  are  an  invaluable  aid  to  the  physician  who  cares 
for  the  sick  infant. 

When  we  go  from  the  individual  to  the  community,  here 
again  the  members  of  the  medical  profession  must  exert 
all  their  efforts  to  dispel  the  dense  clouds  of  ignorance 
which  have  so  closely  surrounded  the  laity.  We  must 
cease  to  allow  the  mothers  to  think  that  diarrheas  are  the 
result  of  teething,  and  must  show  them  that  if  such  were 
true  every  child  would  have  diarrhea  from  the  sixth  to  the 
eighteenth  month,  if  not  continuously  at  least  intermit- 


INTRODUCTION  19 

tently.  We  must  prove  to  them  that  each  child  is  a  law 
unto  itself,  and  that  because  Mrs.  A's  baby,  who  was  fed 
on  condensed  milk,  is  apparently  well,  that  that  in  itself 
is  no  reason  for  believing  that  Mrs.  B's  will  be  the  same. 
We  must  let  them  understand  that  mothers,  for  reason  of 
affection,  if  for  no  other,  never  tell  of  the  countless  numbers 
of  little  ones  past  recall  as  the  result  of  unreasonable  nu- 
trition. 

Babies'  alimentary  canals  vary  as  much  as  their  dispo- 
sitions and  mental  development,  and  most  mothers  are 
intelligent  enough  to  understand  this  if  the  fact  is  only 
brought  to  their  attention. 

The  successful  combating  of  infant  mortality  can  only 
be  brought  about  by  the  education  of  the  mothers  in  the 
essential  facts  of  the  science  of  the  nourishment  of  the  in- 
fant. In  the  future,  however,  there  must  be  facts,  and  not 
unproved  theories.  At  present  the  most  glaring  example 
of  the  harm  that  may  be  done  by  well-intentioned  but  un- 
informed individuals  is  that  of  public  officers  of  health, 
whose  continual  cry  has  been  to  kill  the  bacteria,  and  this 
without  any  reference  whatever  to  the  composition  or 
amount  of  food  to  be  given  the  individual  infant.  No  one 
better  than  the  writer  knows  the  need  and  value  of  pure 
milk,  and  he  certainly  has  no  desire  to  underestimate  the 
great  good  done  in  this  crusade.  This  everyone  sees,  but 
how  many  sec  the  poor,  puny,  marantic  infant  brought  up 
on  condensed  milk  or  malted  milk,  as  the  result  of  the  efforts 
of  the  mother  to  give  it  a  food  which  contains  none  of  the 
death-dealing  (?)  bacteria.  These  and  many  other  abuses 
need  correction,  and  it  is  the  duty  of  the  physician  to  see 
that  his  community  is  properly  informed. 


20  INFANT   FEEDING 

The  general  outline  of  this  work  wiU  be  as  foUows: 
first,  a  few  chapters  which  relate  to  the  anatomy  and  phys- 
iology of  the  gastro-intestinal  tract,  the  metabolism  of  the 
infant,  and  the  bacteriologic  flora  of  the  gastro-intestinal 
canal;  second,  that  most  important  subject,  breast-feeding; 
third,  artificial  feeding  ui  health  and  in  gastro-intestinal 
disturbances;  fourth,  nutrition  of  the  infant  in  diseases  and 
conditions  other  than  those  affecting  the  alimentary  canal. 
An  endeavor  will  be  made  to  combine  the  scientific  and  the 
practical,  a  proposition  which,  on  the  face  of  it,  seems  easy, 
but  which  may  at  times  be  difl&cult  or  impossible  because 
of  the  lack  of  scientific  explanation  for  clinical  facts. 


CHAPTER  II 

SPECIAL  POINTS  IN  THE  ANATOMY  OF  THE  GASTRO- 
INTESTINAL  TRACT   OF   THE   INFANT 

Oral  Cavity. — At  birth  the  salivary  glands  are  well  de- 
veloped, and  the  cells  show  in  them  the  particles  colored 
with  acid  fuchsin,  which  demonstrate  the  presence  of  the 
active  principle  of  the  salivary  secretion. 

The  eruption  of  the  teeth  is  of  much  interest,  mostly 
because  of  the  etiologic  importance  ascribed  by  the  laity 
to  this  process  in  connection  with  summer  diarrhea  and 
other  alUed  disturbances.  The  first  tooth  erupts  usually  in 
the  sixth  month.  It  is  not  a  sign  of  abnormality,  however, 
if  the  eruption  occurs  at  any  time  between  the  fifth  and 
eighth  months.  The  first  teeth  to  appear  are,  as  a  rule,  the 
lower  incisors,  followed,  in  turn,  by  the  upper  incisors 
and  the  canines  and  molars  in  order,  at  about  the  rate  of 
one  a  month.  It  is,  however,  unusual  for  them  to  appear 
at  regular  intervals.  Most  often  they  appear  in  groups, 
followed  by  latent  periods.  Usually  many  days  or  weeks 
intervene  between  the  time  the  tooth  appears  in  the  gum 
and  the  actual  penetration  of  the  mucous  membrane. 
In  this  way  it  is  seen  that  the  process  of  "  teething,"  as  it 
is  viewed  by  the  average  la5'man,  is  almost  a  continuous 
one  from  about  the  sixth  month  to  the  end  of  the  second 
year. 

21 


22 


INFANT  FEEDING 


G 
O 

^3 


(D 


(D 


o 


d 


I 


(D 
(D 

8) 


(D 
(D 

(D 


•fa  & 

•Q      5 


o3 


c   .2 


ANATOMY   OF   THE   GASTRO-INTESTINAL  TRACT 


23 


Esophagus  and  Stomach. — The  esophagus  offers  little  of 
special  interest  from  an  anatomic  standpoint.  The  epi- 
thelium is  soft  and  delicate,  the  papilhe  are  few  and  small. 
Glands  are  usually  lacking. 

At  birth  the  stomach  is  in  form  and  position  midway 
between  the  tubular  type  of  fetal  life  and  the  pouch-like 
organ  of  the  adult.  It  is  nearly  horseshoe  in  shape,  with 
convexity  directed  toward  the  left,  the  whole  completely 
covered  anteriorly  by  the  liver.  By  a--ray  examination 
Major^  has  determined  that  in  erect  position  the  form  of 
the  stomach  is  that  of  a  reversed  retort,  and  that  respira- 
tory movements  of  the  diaphragm  produce  changes  in  the 
position  of  the  stomach  which  are  very  similar  to  peris- 
talsis. The  musculature  is  of  varied  thickness.  The 
mucous  membrane  varies  in  no  essential  way  from  that  of 
the  adult,  except  that  the  gland  cells    are    fewer,  which 


Age. 


Yrs. 


Mos. 


1 

1 

li 

2i 

3 

3 

3| 

8 
11 
12 

2 

5 
10 


^'3 


16.0 
16.3 
14.5 
14.3 
16.7 
17.3 
15.3 
17.0 
17.9 
16.7 
17.5 
19.3 
16.3 
21.0 
2.^.0 
19.5 
22.7 

23-0 
24.6 
28.5 
26.2 


Absolute. 


Relative. 


Capacity  of  the  stomach  with  an  internal 
pressure. 


20.0 
1.8 
1.5 
9.0 
8.0 
40.0 
25.0 
17.0 
28.0 
20.0 
15.0 
3.5 
15.0 
20.0 
60.0 
16.0 
33.0 
10.0 
35.0 
4.^1.0 
31.0 
28.0 


10 


20 


30 


Cubic  centimeters  of  water. 


30 


28.0 

29 

30 

32 

0.56 

4.8 

6 

8 

8 

0.04 

10.0 

16 

19 

23 

0.05 

20.0 

33 

50 

60 

0.31 

21.0 

■M 

59 

76 

0.17 

88.0 

110 

160 

180 

0.77  1 

20.0 

34 

68 

110 

0.42 

63.0 

94 

137 

161 

0.35  I 

85.0 

103 

130 

150 

0.49  1 

54.0 

79 

114 

150 

0.43  1 

44.0 

60 

88 

114 

0.28 

11.0 

17 

55 

110 

0.05 

44.0 

68 

124 

192 

0.35 

93.0 

134 

210 

259 

0.22 

175.0 

255 

355 

416 

0.38 

76.0 

150 

205 

245 

0.22 

90.0 

1.50 

310 

460 

0.28 

33.0 

51 

280 

380 

0.12 

106.0 

180 

400 

530 

0.29 

65.0 

73 

80 

1,50 

0.30 

80.0 

122 

210 

300 

0.14 

120.0 

253 

410 

490 

0.16 

0.781 
0.185 
0.754 
2.052 
1.632 
3.476 
3.071 
3.277 
2.615 
3.221 
2.687 
1.530 
4.433 
2.797 
2.662 
3.304 
3.933 
4.542 
4.356 
1.008 
1.296 
2.725 


Mode  of  nour- 
ishment in  the 
first  half-year 
of  life 


Artificial. 

Breast. 

Artificial. 


Breast. 
Artificial. 


Breast. 
Artificial. 


Breast. 

Artificial. 

Breast. 

Artificial. 


I  Zeitschr.  f.  Ivinderheilk.,  1913,  viii,  340. 


24  INFANT   FEEDING 

anatomic  fact  accounts  for  the  relatively  smaller  amount 
of  gastric  secretion  in  the  infant.  The  capacity  of  the 
stomach  is  a  matter  of  much  clinical  importance,  but  one 
which  is  not  easily  determined  with  any  degree  of  accu- 
racy. The  table  of  Pfaundler's  on  page  23  is  taken  from 
Czerny-Keller,  Bd.  i,  48. 

From  this  may  be  seen  the  extreme  variation  in  the  ca- 
pacity of  the  stomach  under  different  conditions,  part  of 
which  may  be  accounted  for  by  the  variation  in  the  amount 
of  resistance  to  distention  of  the  organ  because  of  the  differ- 
ence in  the  thickness  of  the  musculature.  For  practical 
purposes  the  capacity  given  by  Holt  is  of  sufl&cient  ac- 
curacy: 

At  birth IJ  to  2  ounces. 

At  three  months 4|  ounces. 

At  six  months 6  ounces. 

At  one  year 9  oimces. 

Deserving  of  note  in  this  connection  is  the  so-called 
"  systolic  contracture  "  (Pfaundler)  of  the  stomach.  At  au- 
topsy the  stomach  is  not  rarely  found  in  a  contracted  con- 
dition, with  the  pylorus  hard  and  nodular. 

The  condition  at  the  pylorus  may  lead  one  to  suspect  a 
congenital  stenosis,  but  on  further  examination  it  will  be 
seen  that  the  enlargement  in  the  "  sj^stolic  contraction  " 
is  almost  spheric,  and  readily  disappears  vidth  the  disten- 
tion of  the  stomach,  whereas  the  tumor  in  a  pyloric  stenosis 
is  oblong,  and  does  not  disappear  when  the  stomach  con- 
tains fluid.     (See  Congenital  Pyloric  Stenosis.) 

Intestines.— The  intestinal  glands  and  \illi  of  the  newborn 
are  well  develped.  The  secretoiy  glands  are  seen  strewm 
among  the  mucous  glands  as  far  as  the  descending  colon. 


ANATOMY    OF   THE   GASTRO-INTESTIXAL   TRACT  25 

The  elastic  tissue  is  relatively  small  in  amount;  this  may 
have  some  etiologic  bearing  in  those  cases  of  constipation 
with  accumulation  of  gas  and  distention.  The  elastic 
tissue  in  these  cases  probably  does  not  lend  sufficient  aid 
to  the  circular  muscle  coat. 

In  the  infant  there  is  relatively  less  difference  in  the 
proportional  diameter  and  length  of  the  large  and  small 
intestines.  This  has  been  thought  to  have  some  relation 
to  the  more  frequent  occurrence  of  intussusception  in 
infancy.  The  sigmoid  is  relatively  larger  and  more  mobile 
and  its  position  in  the  abdomen  is  much  more  varied.  Its 
mobility  and  varied  position  is  largely  due  to  the  fact  that 
the  mesosigmoid  is  longer  and  more  elastic.  According  to 
Kleinschmidt^  the  sigmoid  m  infancy  is  frequently  found 
on  the  right  side. 

The  pancreas  shows  no  special  anatomic  features. 

In  the  mfant  the  Hver  is  relatively  much  larger  than  in 
the  adult.  Harley'  gives  the  following  table  of  the  pro- 
portion of  the  hver  weight  to  the  body  weight  at  different 
periods  of  Hfe  ■ 

In  the  newborn 1  to  18 

In  childhood 1  to  20 

At  the  time  of  puberty 1  to  30 

In  the  adult 1  to  35 

In  middle  age 1  to  40 

In  old  age 1  to  45 

From  these  proportions  the  approximate  weight  of  the 
liver  may  be  ascertained.  On  examination  of  the  new- 
bom  the  liver  may  be  felt  in  the  nipple  hne  |  to  f  inch  be- 
low the  costal  margin. 

1  Ergeb.  d.  Inn.  Med.  u.  Kindcrhcilk.,  1912,  i.\,  318. 
*  Quoted  by  Czerny  and  Keller,  Bd,  i,  S.  67. 


26  INFANT   FEEDING 

In  the  newborn  child  the  bile  capillaries  are  found  un- 
changed, but  in  the  children  dead  in  the  first  few  days  of 
life  they  are  found  to  be  tortuous  and  distended,  showing 
here  and  there  small  bulgings  of  the  wall  (Knopf elmacher).^ 
The  bile  in  these  children  shows  a  ^dscidity  greater  than  in 
the  older  infants.  According  to  Knopfelmacher  these 
findings  are  the  result  of  a  venous  stasis,  which  accounts 
for  the  icterus  neonatorum. 

1  Jahrb.  f .  Kinderheilk.,  1908,  Ixvii,  51. 


Yig.  2. — Fat  pad  in  cheek  (Saugpolster). 


CHAPTER  III 

PHYSIOLOGY   OF    THE    GASTRO -INTESTINAL    TRACT 
IN   THE   INFANT 

Oral  Cavity. — ^The  salivary  secretion  is  present  immedi- 
ately after  birth,  but  at  that  time  consists  ahnost  alto- 
gether of  mucus  devoid  of  potassium  sulphocyanid.  The 
reaction  is  neutral  or  weakly  alkaline,  but  soon  after  the 
ingestion  of  milk  becomes  acid,  due  to  the  splitting  of  the 
milk-clots  by  the  bacteria. 

Just  after  birth  the  sucking  of  the  child  is  reflex,  and  is 
carried  on  principally  by  the  pressure  of  the  gums  against 
the  ampullse  of  the  lactiferous  ducts,  the  nipple  being  held 
in  a  trough  formed  by  the  tongue  pressed  against  the  hard 
palate.  Later  in  the  lactation  period  this  primary  sucking 
effort  is  seconded  by  the  voluntary  inspiratory  act. 

In  examining  the  composition  of  the  fat  in  the  cheeks 
Lehndorff  ^  found  that  it  was  poor  in  fatty  acids  and  hence 
not  easily  assimilable.  This  would  account  for  the  fact 
that  in  many  emaciated  children  which  have  not  reached 
the  last  stages  of  marasmus,  but  in  which  the  other  fat  of 
the  body  is  almost  lacking,  the  fat  in  the  cheeks  still  re- 
mains. This  fat  "  polstcr  "  may  show  very  distinctly  in 
thin  young  infants  as  a  small  round  pad  in  each  cheek. 

For  many  years  past,  in  spite  of  the  protests  of  enlight- 
ened members  of  the  profession,  the  physiologic  process  of 

I  Jahrb.  f.  Kinderheilk.,  1907,  Ixv,  286. 

27 


28  INFANT   FEEDING 

"  cutting  teeth  "  has  served  as  the  explanation  for  almost 
all  of  the  disturbances  of  infancy^  especially  of  summer 
diarrhea  and  convulsions.  Though  we  must  admit  that  a 
large  part  of  the  etiology  of  the  two  conditions  named  is  as 
yet  unknoT;^-n  to  us^  still  one  can  hardly  regard  this  as 
sufficient  reason  to  blame  their  occurrence  on  a  perfectly 
normal  process  through  which  every  child  must  go.  As 
has  been  pre^dously  shown,  "  teething  "  is  almost  a  con- 
tinuous process  from  the  sixth  month  to  the  end  of  the 
second  year.  The  mere  fact  that  teething  and  diseases  of 
early  infancy,  notably  summer  diarrhea  and  convulsions, 
occur  contemporaneously  should  not  lead  us  astray  in  our 
diagnosis. 

There  is  nothing  in  the  anatomic  relations  of  the  teeth 
which  can,  in  even  a  remote  way,  lead  to  the  suggestion  of 
a  connection  between  the  teeth  and  the  intestines.  "  Re- 
flex action  "  has  been  advanced  as  a  theory  of  the  mode  of 
action  of  this  process,  but  for  this  no  facts  have  been  given 
in  support. 

On  the  other  hand,  it  is  not  unreasonable  to  think  that 
the  cutting  of  teeth  may  be  accompanied  by  pain,  since  it 
is  known  that  in  the  adult  the  appearance  of  the  third 
molar  teeth  sometimes  brings  "^ith  it  a  certain  amount  of 
ache  in  the  alveolar  processes.  That  pain  is  present  in  all 
cases  is  certainly  not  true,  since  some  babies  cut  their  teeth 
without  any  manifestations  of  discomfort.  As  to  others, 
the  most  that  can  be  said  is  that  apparently  just  before 
the  teeth  pierce  the  gums  they  seem  to  be  in  much  pain, 
which  is  sometimes  relieved  by  pressure  on  the  gums. 

During  the  time  when  the  teeth  are  about  to  pierce  the 
mucous  membrane  there  is  often  an  increase  in  the  amount 


PHYSIOLOGY    OF   THE    GASTRO-INTESTINAL   TRACT        29 

of  the  salivary  secretion,  which  is  shown  by  the  drooHng 
of  the  child. 

Stomach. — The  motor  activity  of  the  stomach  in  the 
infant  is  of  much  importance  because  of  its  relation  to 
vomiting  and  to  the  length  of  the  interval  between  feedings. 
The  work  of  Cannon  on  animals  can  probably  scr\'c  as  a 
basis  for  our  knowledge  of  the  opening  and  closing  of  the 
pylorus,  which  is  the  most  essential  factor  in  the  motor 
activity  of  the  organ.  From  Carmon's  findings  we  may  de- 
duce that  an  acid  reaction  of  the  contents  of  the  pyloric 
region  of  the  stomach  causes  opening  of  the  pylorus,  while 
an  acid  reaction  in  the  duodenum  causes  it  to  remain 
closed.  After  the  coagulation  of  the  milk  in  the  stomach 
the  contents  consist  of  whey  and  curds.  The  former  is 
readily  acidified  and,  therefore,  passes  the  pylorus  first, 
together  with  any  added  carbohydrates  which  happen  to 
be  present.  The  protein  requires  a  longer  time,  since 
the  acid  of  the  stomach  is  combined,  and  hence  a  certain 
time  elapses  before  free  acid  is  present.  The  fatty  acids  and 
neutral  fats  are  the  last  to  pass  the  pyloms,  not  because 
they  do  not  easily  acidify,  but  because  it  takes  much 
longer  for  the  fatty  acids  to  be  neutralized  by  the  duod- 
enal juices,  and  hence  the  pylorus  remains  closed  because  of 
duodenal  acidity.  We  readily  see,  then,  that  a  high  fat-con- 
tent of  the  food  delays  its  passage  through  the  pylorus. 
Extreme  dilution  acts  in  the  same  way,  probabl}'  because 
of  the  slight  stimulation  of  the  gastric  mucosa,  resulting  in 
reduced  secretion  and,  hence,  acidity.  The  stomach  is 
emptied  much  more  quickly  in  the  breast-fed  infant,  the 
average  being  about  two  hours.  The  time  varies  with 
the  amount  taken.     As  to  cows'  milk,  the  same  restrictions 


30  INFANT   FEEDING 

must  be  made,  but  in  the  majority  of  cases  the  food  leaves 
the  stomach  only  after  three  hours.  These  conclusions 
are  not  absolutely  reliable  because  of  our  methods  of  es- 
timation. Up  to  the  present  time  two  methods  have  been 
employed  for  determining  the  length  of  time  the  food  re- 
mains in  the  infant's  stomach.  To  the  first  of  these,  gastric 
lavage,  may  be  objected  that  all  food  cannot  be  removed  in 
this  way,  and  hence  the  length  of  time  that  the  food  remains 
in  the  stomach  cannot  be  accurately  determined.  The 
second,  by  means  of  the  bismuth  meal  and  the  a;-ray,  has 
recently  been  studied  by  Pisek  and  Lewald,^  Ladd,^  and 
Major.^  The  findings  in  general  point  to  a  distinct  indi- 
vidual difference  in  the  length  of  time  that  food  remains  in 
the  stomach.  To  this  method  may  be  objected  that  the 
bismuth  adds  a  substance  which  is  not  normally  present. 
In  general  it  may  be  said,  however,  that  the  statement  that 
food  is  found  in  breast-fed  infants,  under  ordinary  condi- 
tions, usually  at  least  two  hours  after  feeding,  and  in  arti- 
ficially fed  three  hours,  is  correct.  However,  individual 
cases  may  vary  greatly  from  this  general  rule. 

In  the  stomach  of  a  four  months'  fetus  there  is  digestive 
activity,  rennet  is  nearly  always  present,  as  is  also  pepsin, 
if  there  is  any  acidity.  The  acidity  of  the  gastric  juice 
is  due  to  several  substances:  first,  to  HCl  and  HCl-albumin 
bodies,  albumose  and  peptone;  second,  to  lactic  acid;  third, 
to  fatty  acids;  fourth,  to  phosphoric  acid,  acid  phosphates, 
and  the  inorganic  acid  bodies  formed  by  action  of  HCl  on 
the  salts;  and  fifth,  to  other  acid  substances  in  human 

1  Amer.  Jour.  Dis.  of  Child.,  1913,  vi,  232. 

2  Ibid.,  V,  345. 

3  Zeitschr.  f.  Kinderheilk.,  1913,  viii,  340. 


PHYSIOLOGY    OF   THE   GASTRO-LNTESTIXAL   TRACT       31 

milk.  According  to  Davidsohn,^  hydrochloric  acid  in  the 
infant's  stomach  shows  no  real  difference  from  that  of  the 
adult,  variations  being  due  to  difference  in  choice  of  test- 
meals.  The  free  HCl  increases  as  digestion  advances; 
hence,  the  longer  the  interval  Ix^tween  feedings  the  more 
free  HCl  is  jjrcscnt,  and  the  greater  the  bactericidal  action 
of  the  gastric  juice.  As  in  the  adult,  the  HCl  acts  as  an 
aid  to  peptic  digestion,  splits  the  sugars,  and,  if  in  sufficient 
strength  (.07  to  .08  per  cent.),  inhibits  the  production  of 
lactic  acid,  and  acts  as  a  disinfectant.  The  HCl  possesses 
two  other  properties  which  are  of  much  importance  to  the 
infant:  it  is  a  good  detoxicant,  being  a  great  aid  in  the 
destruction  of  animal  and  vegetable  toxins,  and  it  also  is 
a  good  denaturizing  agent,  which  robs  foreign  albumin  of 
the  property  of  being  able  to  produce  antibodies.  From 
the  action  of  HCl  and  other  digestive  substances  the  casein 
of  cows'  milk  is  thus  prevented  from  producing  any  specific 
poisons  in  the  infant  organism.  Hess"  has  found  free  hydro- 
chloric acid  in  the  stomach  immediately  after  birth  in  54 
out  of  55  cases,  in  most  of  them  in  large  amounts.  This 
presents  an  interesting  problem  in  that  the  stimulation  of 
the  gastric  glands  cannot  be  accounted  for  in  the  usual  way. 
The  action  of  rennet  is  the  same  as  in  the  adult,  but  not  so 
marked,  because  of  the  smaller  quantity  of  the  ferment. 
The  casein  is  coagulated  into  paracasein,  which  contains 
much  calcium  phosphate.  In  reality,  the  clots  of  cows'  milk 
are  probably  no  larger  than  those  of  human  milk  (although 
test-tube  experiments  would  tend  to  show  the  opposite), 
since  the  motor  activity  of  the  stomach  tends  to  keep  the 

'  Zeitschr.  f.  Kinderheilk.,  1912,  iv,  20S. 
*  Amer.  Jour.  Dis.  of  Child.,  1913,  vi,  264. 


32  INFANT   FEEDING 

curd  well  broken  up.  Coagulated  milk  requires  less  HCl 
than  does  uncoagulated.  The  coagulation  is  naturally  in- 
fluenced by  such  factors  as  the  constituents  of  the  food, 
the  dilution,  previous  heating,  and  the  presence  of  clots 
from  previous  feedings.  As  to  the  true  function  of  rennet 
we  know  very  little:  it  may  be  that  its  action  only  delays 
the  absorption  of  the  casein. 

Pepsin  is  frequently  present  and,  according  to  most  writers, 
splits  the  protein  molecule  as  far  as  peptone,  but  Salge^ 
thinks  that  the  hydrogen  ion  concentration  in  the  stomach 
is  so  slight  that  pepsin  digestion  is  not  possible  even  in  the 
normal  infant.  We  are  as  yet  uncertain  as  to  how  import- 
ant for  protein  digestion  the  action  of  pepsin  is,  but  that  a 
certain  amount  of  digestion  is  carried  on  by  the  pepsin  is 
undoubtedly  true.  There  is  little  difference  in  its  digestive 
action  on  cows'  and  human  milk.  Like  HCl,  pepsin  acts 
as  a  denaturizer. 

Lipase,  the  fat-splitting  ferment,  is  found  in  the  stomach 
of  the  infant  in  small  quantities.  It  is  probably  a  defi- 
nite product  of  the  gastric  mucosa.*  As  in  the  adult,  the 
gastric  mucosa  of  the  infant  is  stimulated  directly  (e.  g., 
by  contact  with  food)  or  psychically  (e.  g.,  by  sucking  on 
the  breast  or  bottle).  The  amount  of  the  secretion  is  in- 
fluenced very  much  by  the  character  of  the  food  ingested, 
a  proportionately  large  quantity  of  fat  distinctly  inhibit- 
ing its  formation.  The  maximum  secretion  is  usually  not 
reached  for  three  hours.  Absorption  from  the  stomach 
is  more  rapid  in  the  infant  than  in  the  adult. 

Pancreas. — ^The  pancreas  of  the  newborn  contains  all  the 

1  Zeitechr.  f.  Kinderheilk.,  1912,  iv,  171. 

2  Sedgwick  and  Schlutz,  Amer.  Jour.  Dis.  of  Child.,  1911,  ii,  243. 


PHYSIOLOGY   OF   THE   GA8TRO-INTESTINAL   TRACT        33 

ferments  found  in  the  adult,  but  in  much  smaller  quantity. 
This  is  proved  by  the  findings  of  Lust  and  Hahn^  in  the 
stool,  and  by  Hess^  with  the  duodenal  catheter.  Lust  and 
Halm  have  found  all  of  the  pancreatic  ferments  in  the  in- 
fants' stools  examined.  The  action  of  the  trypsin  is  com- 
pleted with  the  assistance  of  the  erepsin  of  the  succus  en- 
tericus,  and  is  greatly  aided  by  a  strong  action  of  the  gastric 
juice.  As  in  the  adult,  the  end-products  of  protein  diges- 
tion are  the  amino-acids.  The  steapsin  is  much  weaker 
than  in  the  adult,  but  here  also  its  action  is  aided  by  the 
biliary  salts.  Amylopsin  is  always  present  in  small  quanti- 
ties, but  lactase  and  invertin  are  never  found  in  the  newborn. 

Liver. — The  liver  possesses  the  ability  to  form  glycogen 
and  urea  in  the  newborn.  Of  much  importance  for  the 
infant  is  the  protection  against  poisons  offered  by  the 
liver.  This  acts  on  all  sorts  of  poisons,  such  as  toxins  of 
Bacillus  coli  communis,  toxic  products  from  the  intestinal 
canal,  as  well  as  upon  alcohol  and  alkaloids,  such  as  mor- 
phin  and  strychnin.  Bile  is  present  in  fetal  life,  and  pos- 
sesses the  ability  to  dissolve  fatty  acids. 

The  succus  entericus  at  birth  contains  enterokinase, 
erepsin,  lactase,  invertin,  and  maltase. 

The  permeability  of  the  gastro-intestinal  wall  is  the 
same  as  in  the  adult  for  the  end-products  of  digestion.  It 
is  undoubtedly  true  that  in  the  vast  majority  of  cases  al- 
bumins cannot  pass  the  gastro-intestinal  wall  of  the  in- 
fant unchanged,  but  in  certain  cases  there  are  idiosyncrasies 
against  cows'  or  human  milk.  Although  no  direct  proof 
offers,  there  is  reason  to  believe  that  small  quantities  of 

1  Monatsschr.  f.  lOnderheilk.,  1912,  xi,  311. 

2  Amer.  Jour.  Dis.  of  Child.,  1912,  iv,  205. 
3 


34  INFANT   FEEDING 

foreign  albumin  pass  through  the  intestinal  wall  unchanged 
and  give  rise  to  symptoms  of  an  anaphylactic  nature. 
In  nutritionally  deranged  infants,  Lust^  has  recently  shown 
that  egg  albumen  is  present  in  the  urine  in  the  severer  cases. 
Hahn^  has  had  much  the  same  results  with  antitoxin.  Lust's^ 
results,  however,  with  bovine  albumen  were  not  so  conclusive. 
Antitoxic  bodies  (diphtheria  antitoxin)  contained  in  the 
mother's  milk  are  not  absorbed  unchanged.  It  is  probable 
that  some  highly  resistant  bacteria,  such  as  the  tubercle 
bacillus  (Uffenheimer),  pass  through  the  intestinal  wall, 
perhaps  enclosed  in  fat-globules. 

General  Conclusions. — In  a  general  way,  then,  we  see 
that  the  infant's  gastro-intestinal  tract  is  perfectly  able  to 
digest  and  absorb  aU  food-stuffs,  but  in  relatively  less 
amount  than  in  the  adult.  When  we  realize  that  we  have 
to  do  with  an  ahmentary  system  in  the  formative  stage, 
and  that  this  undeveloped  group  of  organs  is  called  upon 
not  only,  as  in  the  adult,  to  make  good  the  body  waste,  but 
also  to  supply  tissue  for  the  formation  of  the  growing  body, 
and  that,  too,  at  a  time  when  the  body  growth  is  relatively 
much  greater  than  at  any  subsequent  period  of  life,  we  may 
readily  account  in  large  measure  for  the  frequent  gastro- 
intestinal disturbances  in  the  first  and  second  years.  An- 
other function  not  less  important  is  the  denaturizing  and 
detoxicant  action  of  the  infant's  gastro-intestinal  tract. 

In  regard  to  the  fat  digestion  and  absorption,  there  has 
been  in  the  past  much  controversy,  caused  no  doubt,  in 
large  part,  by  the  difficulty  in  differentiating  accurately 

1  Jahrb.  f .  Kinderheilk.,  1913,  Ixxvii,  243. 

2  Ibid.,  405. 

3  Ibid.,  383. 


PHYSIOLOGY   OF   THE   CASTRO-INTESTINAL   TRACT       35 

in  the  stools  the  various  foniis  of  fat.  A  recent  article  of 
Usuki'  is  probably  most  reliable  because  of  tlie  perfection 
of  his  technic.  He  found  that  about  09  per  cent,  of  the  food 
fat  was  split  by  the  intestinal  juices,  and  that  only  VA  to 
13.5  per  cent,  of  this  was  found  in  the  feces.  The  fat  in 
the  normal  feces  consisted  of  about  10  per  cent,  neutral 
fat,  10  per  cent,  earthy  soaps,  and  the  rest  fatty  acids. 

»  Jahrb.  f.  Kinderheilk.,  1910,  Ixxii,  18. 


CHAPTER  IV 

ABSORPTION  AND   METABOLISM 

In  considering  absorption  and  metabolism  we  must 
bear  in  mind  several  things.  In  the  first  place,  metabolic 
experiments  on  infants  are  based  on  examinations  of  feces 
and  mine  collected,  as  a  rule,  during  a  period  of  three  days. 
That  many  clinical  facts  cannot  in  this  way  be  adequately 
accomited  for  is  self-evident.  The  difficulty  and  tedious- 
ness  of  these  investigations  is  such  that  it  requires  a  long 
time  and  a  well-equipped  laboratory  to  do  what  seems  to 
be  a  small  amount  of  work.  This  necessitates  basing  our 
conclusions  on  a  comparatively  small  material,  and  that, 
too,  in  a  subject  which  is  notably  individual  in  its  character. 
Be  this  as  it  may,  metabohc  experiments  have  blazed  the 
trail  for  the  most  important  of  our  cUnical  advances  in  the 
subject  of  infant  feeding,  and  as  time  adds  new  facts  we 
are  enabled  to  place  a  more  definite  conclusion  on  those 
already  at  hand. 

Protein  Metabolism. — AU  experiments  to  date  go  to 
prove  that  the  protein  of  cows'  milk  is  as  weU  taken  care 
of  by  the  infant's  metabolism  as  is  that  of  human  milk. 
It  has  been  shown  that  where  hke  quantities  of  nitrogen 
are  ingested,  hke  quantities  are  excreted  in  the  feces. 

It  is,  however,  undoubtedly  true  that  more  albumin  is 
excreted  in  the  stools  of  artificially  fed  infants  than  in 
breast  fed.     This,  perhaps,  is  due  to  the  ingestion  of  a  larger 

36 


ABSORPTIOxV    AND    METABOLISM  37 

amount  of  casein,  but  in  all  probability  it  is  in  larger  meas- 
ure due  to  the  increase  of  albumin  products,  due  in  turn  to 
the  greater  irritation  caused  by  cows'  milk,  and  to  the 
fact  that  this  favors  the  growth  of  intestinal  bacteria. 
The  sources  of  nitrogen  in  the  stool  are  four:  nitrogen  of  the 
food,  epithelial  cells,  digestive  and  intestinal  juices,  es- 
pecially mucus,  and  bacteria.  In  the  pathologic  stool  the 
mucus  and  bacteria,  in  the  normal  stool  the  bacteria  alone, 
probably  contain  the  bulk  of  the  nitrogen.  This  is  most 
readily  shown  by  the  fact  that  increase  of  the  protein-con- 
tent of  the  food  is  not  followed  by  increase  of  the  stool- 
nitrogen,  independent  of  whether  the  food  is  raw,  cooked,  or 
sterilized.  However,  in  food  rich  in  starch  the  stool-nitro- 
gen is  increased,  due  no  doubt  to  the  increased  intestinal 
irritation.  In  hunger,  the  nitrogen  of  the  stool  is  propor- 
tionately increased  because  of  the  catabolism  of  the  body 
proteins.  After  hunger,  nitrogen  is  stored  up.  A  high  fat- 
content  in  the  food  does  not  save  the  nitrogen  from  waste, 
but  malt,  milk,  and  cane-sugar,  and  sometimes  starch 
seem  to  aid  nitrogen  retention.  It  is  reasonable  to  su impose 
that  if  the  body  could  be  observed  over  a  long  period  the 
retention  of  nitrogen  would  go  hand  in  hand  with  that  of 
phosphorus  and  chlorin,  but  when  one  confines  himself  to 
short  periods  this  is  not  always  the  case.  If  lecithin  (or- 
ganic compound  containing  phosphorus)  be  added  to  the  fat, 
it  is  noted  that  nitrogen  retention  is  favored.  Chlorin  and 
nitrogen  are  retained  at  the  same  time,  but  the  quantities 
vary.  For  a  short  period  only,  nitrogen  retention  may  take 
place,  independent  of  salt  retention.  In  general,  we  may 
say,  then,  that  the  carbohydrates  favor  nitrogen  reten- 
tion, while  fat  favors  nitrogen  excretion.     There  seems  to 


38  INFANT   FEEDING 

be  a  certain  parallelism  between  nitrogen  retention  and 
that  of  the  various  salts. 

In  the  baby  fed  on  breast-milk  the  nitrogen  excretion 
in  the  feces  and  urine  increases  with  age.  The  retention 
of  the  nitrogen  is  rather  independent  of  the  nitrogen  in- 
gested in  the  healthy  baby,  but  in  the  sick  one  the  ability 
to  retain  nitrogen  is  reduced  until  convalescence  sets  in, 
when  it  is  about  the  same  as  in  the  healthy  infant.  In 
the  younger  babies  the  ability  to  retain  nitrogen  on  ar- 
tificial feeding  is  no  less  than  in  the  breast  fed,  but  in 
the  older,  artificially  fed  infants  nitrogen  is  better  retained 
than  in  those  naturally  nourished. 

Langstein  and  Nieman/  in  examining  newborn  infants, 
found  that  in  the  first  five  to  eight  days  there  was  a  neg- 
ative nitrogen  balance,  and  that  only  after  this  time  was 
there  a  slow  nitrogen  retention.  This  they  ascribe  to  tissue 
destruction.  Birk,^  by  feeding  colostrum  instead  of  human 
milk,  has  disproved  these  findings,  showing  under  normal 
conditions  that  there  is  distinct  retention  of  nitrogen  and 
ash  during  the  first  days  of  life. 

In  regard  to  the  division  of  the  nitrogen  in  the  food,  a 
few  important  articles  have  recently  been  written.  Am- 
berg  and  Merrill^  examined  a  normal  child  at  frequent 
intervals  over  some  months,  and  came  to  the  conclusion 
that  in  a  completely  normal  breast-fed  infant  a  food  poor 
in  albumin  shows  an  increased  ammonia  coefficient,  to- 
gether with  an  increased  excretion  of  uric  acid  and  cre- 
atinin.     To  a  certain   extent  the  increased  ammonia  is 

1  Jahrb.  f .  Einderheilk.,  1910,  Ixxi,  604. 

2  Monatsschr.  f.  Kinderheilk.,  1910  ix  (Orig.),  515. 

3  Jahrb.  f .  Kinderheilk.,  1909,  Ixix,  280. 


ABSORPTION    A.VD    METABOLISM  39 

dependent  upon  an  increased  fat-content  of  the  food. 
The  work  of  Vogt'  was  carried  on  principally  in  children 
suffering  from  various  nutritional  disturbances.  He  found 
that  while  in  some  children  with  chronic  nourishment  dis- 
turbances the  ammonia  coeflBcient  remained  unchanged, 
in  others,  in  which  there  was  an  "outspoken  intolerance 
for  milk-fat,"  the  ammonia  coefficient  was  distinctly  in- 
creased. 

Birk^  has  shown  that  in  the  artificially  nourished  infant 
one-half  of  the  ingested  nitrogen  is  given  off  in  the  urine, 
while  in  the  naturally  nourished  one-sixth  to  one-seventh  is 
found  there.  Bahrdt  and  Bamberg^  have  determined  that 
by  the  addition  of  slight  doses  of  acetic  acid  to  the  food  there 
is  a  better  use  of  the  nitrogen,  ash,  and  calcium  in  the  in- 
testines. 

In  the  newborn  and  in  the  child  on  the  breast  Vogt  found 
that  a  high  percentage  of  the  nitrogen  in  the  urine  came 
from  ammonia,  uric  acid,  creatinin,  etc.  In  parenteral 
infection  the  nitrogen  division  in  the  urine  remained  un- 
changed. In  acute  nourishment  disturbances  the  am- 
monia and  allied  nitrogen-containing  substances  in  the 
urine  were  increased.  Sedgwick,'*  in  examining  the  urine 
of  the  newborn  infant  for  creatinin,  found  this  substance  to 
be  present  in  a  proportion  the  same  as  that  of  the  adult. 
In  older  infants  the  creatinin  was  proportionately  reduced. 
Creatin.  is  more  frequently  present  in  the  urine  of  children 
than  in  that  of  adults.     Niemann^  has  determined  that  the 

1  Monatsschr.  f.  Kinderheilk.,  1909,  viii,  57,  121. 

*  Ibid.,  1910  X  (Orig.),  1.  ,      ' 
» Zeitschr.  f.  Kinderheilk.,  1912,  iv,  534. 

*  Jour.  .\mer.  Med.  Assoc,  1910,  Iv,  1178. 
» Jahrb.  f.  Kinderheilk.,  1910,  bcxi,  286. 


40  INFANT   FEEDING 

variation  of  the  uric  acid  in  infants  is  not  essentially  differ- 
ent from  that  in  adults  after  the  first  few  days  of  life.  Von 
Reuss^  found  that  glycocoU  was  constantly  present  in  the 
infants'  urine.  He  found  also  that  indican  is  present  in  the 
first  day  of  life,  more  rarely  on  the  second,  and  comes  more 
frequently  on  the  fourth.  He  regards  it  as  a  derivative  of 
the  indol  from  intestinal  secretion  or  a  sign  of  tissue  destruc- 
tion.2  Helmholz  and  Amberg^  have  found  that  there  is  a 
fraction  of  a  per  cent,  of  hippuric  acid  in  infants'  urine. 
(It  might  be  stated  here  that  Liefmann,^  in  examining  the 
acetone  content  of  the  infants'  urine,  found  in  the  normal 
infant  a  value  of  not  over  .7  mgm.  in  twenty-four  hours. 
He  also  found  that  the  amount  of  acetone  was  distinctly 
increased  in  spasmophilic  infants.) 

We  see,  therefore,  that  the  end-products  of  protein  di- 
gestion are  present  in  the  infant's  urine,  but  that  especially 
the  ammonia-content  shows  wide  variations  in  different 
conditions. 

Fat  Metabolism. — An  examination  of  the  fat  in  the  body 
of  the  fetus  and  newborn  shows  that  it  approaches  in  com- 
position that  of  the  milk-fat,^  and  that  it  slowly  loses  this 
chemical  composition  toward  the  end  of  the  first  year. 
No  material  of  the  body  is  so  variable  as  the  body-fat, 
since  it  is  used  as  combustible  material  when  the  intes- 
tinal tract  is  unable  to  provide  the  proper  material  for 
this  purpose.  In  the  body  of  the  newborn  the  proportion 
of  fat  is  greater  than  in  the  adult.     The  amount  of  fat 

^  Wien.  klin.  Wochenschr.,  1909,  xxii,  158. 

2  Zeitschr.  f.  I^iderheilk.,  1911,  iii,  12. 

2  Ibid.,  1913,  ix,  6. 

*  Jahrb.  f .  Kinderheilk.,  1913,  bmi,  125. 

'  Engel,  Monatsschr.  f .  Kinderheilk.,  1909,  viii,  618. 


ABSORPTION    AND    METABOLISM  41 

later  found  in  the  body  is  largely  dependent  upon  the  as- 
similation and  composition  of  the  food,  the  fat  children 
being  those  fed  on  breast-milk  or  large  quantities  of  cows' 
milk,  with  full  amounts  of  carbohydrates.  As  we  will  see 
later,  obesity  of  the  baby  is  as  much  a  pathologic  condition 
as  that  of  the  adult. 

From  87  to  98  per  cent,  of  the  fat  ingested  is  absorbed, 
and,  as  previously  mentioned,  practically  all  the  fat  is 
split  in  the  intestinal  canal.  The  fat  thus  absorbed  is 
used  for  energy,  but  it  is  altogether  likely  that  there  is  an 
intimate  relation  between  the  fat  metabolism  and  the  resist- 
ance of  the  child  to  infection.  A  food  poor  in  fat  contin- 
ued over  a  long  period  certainly  reduces  the  resistance  of 
the  child  to  infections  of  various  kinds. 

In  the  infant  there  exists  a  tendency  to  acidosis,  prob- 
ably due  to  disturbance  of  fat  metabolism,  as  a  result  of 
deficiency  of  the  metabolic  products  of  the  carbohydrates. 
This  is  most  marked  in  the  more  acute  nourishment  dis- 
turbances, but  is  found  in  various  other  conditions.  (See 
Ammonia  Coefficient.) 

Fat  in  the  food  tends  to  lower  the  nitrogen  retention, 
i.  e.,  the  more  fat,  the  less  nitrogen  retained.  In  a  general 
way  the  fat  favors  the  storage  of  inorganic  materials  as  a 
whole,  but  slowly  reduces  the  retention  of  calcium  and 
phosphorus.  An  excess  of  fat,  by  aiding  in  the  formation 
of  the  soap  stool,  favors  the  excretion  of  alkalis  from  the 
system  (relative  acidosis).  High  casein  and  calcium  con- 
tents in  the  food  favor  the  formation  of  soap  stools.  Aschen- 
heim,^  however,  has  shown  that  soap  stools  sometimes  result 
from  fat-free  and  calcium  poor  nourishment.  The  findings 
1  Jahrb.  f.  Ivinderheilk.,  1913,  Lxxvii,  505. 


42  INFANT  FEEDING 

of  Usuki,  however,  would  lead  one  to  think  that  the  soap 
stool  represented  a  condition  not  of  poor  fat  absorption, 
but  perhaps  a  disturbance  of  fat  metabolism  due  to  excess- 
ive fat  absorption. 

According  to  Bahrdt^  the  soap  stool  is  accompanied  by  a 
decreased  absorption  of  fatty  acids;  this  he  thinks  is  due  to 
the  increased  peristalsis  in  the  small  intestine,  together 
with  increased  excretion  of  alkah,  which  favors  the  forma- 
tion of  the  soap  stool  in  the  colon. 

Carbohydrate  Metabolism. — Because  of  the  fact  that  the 
end-digestive  products  of  the  carbohydrates  cannot  be 
recognized  as  such,  it  has  been  very  difficult  to  determine 
the  exact  position  of  these  food-stuffs  in  relation  to  metabo- 
lism. Sugar  is  found  in  the  stool  in  only  minute  quantities, 
and  then  not  constantly,  and  starch  appears  in  variable 
quantities  (as  shown  by  the  iodin  test),  dependent  upon 
the  amount  in  the  food  and  the  age  of  the  infant.  Milk- 
sugar  probably  requires  a  longer  time  to  be  absorbed  than 
does  malt-sugar,  while  cane-sugar  seems  to  be  distinctly 
irritating  to  the  intestines  of  the  young  infant.  In  severe 
nutritional  disturbances,  lactose,  galactose  (Finkelstein), 
and  even  saccharose  (von  Reuss)^  are  to  be  found  in  the 
urine.  RietscheP  has  also  shown  that  after  a  hunger  period 
of  two  to  three  days  the  oral  ingestion  of  sugar  solution 
produced  a  glycosuria,  from  which  he  draws  the  conclusion 
that  there  is  produced  by  the  hunger  period  an  injury  to  the 
epithelial  lining  of  the  intestines.  An  interesting  finding  is 
that  of  Nothmann,*  who,  in  examining  the  stools  of  pre- 

1  Jahrb.  f.  Kinderheilk.,  1910,  Ixxi,  249. 

2  Wien.  klin.  Wochenschr.,  1910,  xxiii,  123. 

3  Zeitschr.  f.  Kinderheilk.,  1913,  vii,  282. 

4  Monatsschr.  f.  Kinderheilk.,  1909,  viii,  377. 


ABSORPTION    AND    MP:TAB0LISM  43 

mature  infants  (breast  fed),  found  lactase  in  every  case, 
and  in  the  urine  of  these  same  babies,  by  the  osazone  test, 
was  able  to  detect  sugar;  however,  this  was  not  always  pres- 
ent. All  the  children  did  well  and  made  normal  gains  in 
weight  without  showing  any  signs  of  gastro-intestinal  dis- 
turbance. This  glycosuria  he  regards  as  of  distinctly  other 
origin  from  that  encountered  in  intoxication.  The  recent 
experiments  of  Meigs^  and  others  have  disproved  the  theory 
of  Leopold  and  von  Reuss^  that  the  injection  of  a  sugar  solu- 
tion produced  a  rise  in  temperature.  It  has  been  shown 
very  conclusively  during  the  last  year' that  such  rise  in 
temperature  is  probably  due  to  the  bacterial  content  of 
distilled  water. 

In  the  body  of  the  infant  sugar  seems  to  act  greatly  like 
an  inorganic  salt.  It  seems  to  favor  a  retention  of  water  in 
the  system.  This  is  loosely  combined  and  is  probably  held 
in  the  subcutaneous  tissue.  This  theory  is  supported  by  the 
findings  of  Carneiro,^  who  showed  that  by  withdrawal  of  the 
carbohydrates  in  the  normal  infant  there  was  a  distinct  loss 
in  weight.  This  loss  in  weight,  however,  was  accompanied 
by  loss  of  nitrogen  and  salts,  including  chlorin.  A  good  ex- 
ample of  this  is  in  those  cases  of  long  overfeeding  with  sugar 
(especially  in  the  form  of  condensed  milk).  Should  one  of 
these  children  suddenly  be  taken  with  an  intoxication,  the 
loss  of  weight  is  so  rapid  and  large  as  to  jeopardize  the 
life  of  the  child.  This  can  only  be  explained  by  the  loss  of  a 
large  quantity  of  water  (in  the  form  of  solution  of  salt  which 
is  very  loosely  held   in  the   tissues).     Another  important 

1  Reported  at  Chicago  Pod.  Soc,  May  26,  1913. 
*  Monatssohr.  f.  Kinderheilk.,  1909,  viii,  1,  453. 
» Ibid.,  1913,  xu,  333. 


44  INFANT   FEEDING 

action  of  the  sugar  is  the  production  of  fever.  This  is 
analogous  to  the  "salt  fever"  (see  later).  It  is  not  con- 
stant, but  does  occur  under  certain  conditions  and  in  certain 
organisms,  and|]this  fever  is  that  of  "alimentary  intoxication," 
as  described  by  Finkelstein.  Sainmont^  has  also  shown  that 
cane-sugar  and  dextrose  have  a  toxic  action  on  dogs. 

Within  the  last  two  years  not  only  the  sugar  but  other 
carbohydrates  have  received  exhaustive  attention.  South- 
worth^  has  called  attention  to  the  value  of  dextrin  in  infant 
foods,  and  thinks  that  we  should  lay  more  stress  on  dex- 
trin as  a  constituent  of  the  various  malt  foods.  For  the 
digestion  of  starch  the  duodenal  secretion  is  of  the  great- 
est importance.  It  is  distinctly  proved  that  intestinal 
bacteria  tend  to  form  acids  when  there  is  an  appreciable 
quantity  of  starch  in  the  food.  This  acid  formation  is 
ordinarily  not  abnormal,  but  may  easily  increase  to  a 
point  where  it  produces  symptoms.  By  the  addition  of 
malt  to  the  various  meals,  Klotz^  has  shown  that  the 
combination  of  wheat  flom*  and  malt  extract  is  the  hardest 
to  ferment  and  produces  the  smallest  amount  of  acids,  while 
an  oatmeal  and  malt  extract  produces  the  most.  In  regard 
to  the  metabolism  he  shows  that  starches  spare  the  protein 
and  fat  and  produces  a  distinct  water  retention. 

Inorganic  Salts. — In  very  recent  years  the  inorganic  salts 
have  attracted  more  and  more  attention.  Meyer*  estimates 
that  the  normal  breast-fed  infant  takes  about  140  liters  of 
breast-milk  in  the  first  six  months  of  its  existence,  and  that 

1  Monatsschr.  f.  Kinderheilk.,  1912,  x,  579. 

2  Arch,  of  Ped.,  1912,  xxix,  646. 

» Ergeb.  d.  inn.  Med.  u.  Kinderheilk.,  1912,  viii,  593. 
*  Jahrb.  f.  Kinderheilk.,  1910,  Ixxi,  1. 


ABSORPTION    AND    METABOLISM  45 

with  this  salts  are  consumed  in  approximately  the  following 
amounts: 

Total  ash 120-140  grama. 

K,0 30-  58  " 

CaO 26-  50  " 

CI 24 

Na,0 10-  12  " 

P,05 12-  16  " 

MgO 6 

FeaOa 2-    3  " 

The  intestine  is  not  only  the  place  of  absorption,  but  also 
of  excretion  (in  large  part)  of  the  inorganic  matter,  and 
especially  of  the  calcium.  In  general,  the  ideas  regarding  the 
action  of  salts  have  changed  during  the  last  year.  It  has 
been  conclusively  shown  (Jorgensen  and  others^  that  the 
rise  in  temperature  produced  by  subcutaneous  injection  of 
salts  is  due  to  the  use  of  distilled  water  which  is  not  fresh, 
and  which  probably  contains  the  dead  bodies  of  bacteria. 

As  to  oral  ingestion  of  salts,  Heim-  thinks  that  the  fever 
thus  produced  is  due  to  the  hydropigenous  action  of  the 
salt,  and  Schloss^  thinks  that  the  action  of  salts  is  a  general 
and  not  a  specific  one  and  is  due  to  the  concentration  of 
the  salt  itself  and  the  individual  predisposition  of  the  sub- 
ject, thus  in  the  main  agreeing  with  Heim. 

Of  all  the  salts,  probably  the  most  important  and,  there- 
fore, the  most  studied  are  those  of  calcium  and  sodium. 

Rothberg,*  in  studying  the  calcium  vietabolism  of  the 
infant,  came  to  the  conclusion  that  the  retention  of  calcicum 
depended  upon  the  processes  of  intermediary  metabolism 

1  Monatsschr.  f.  Kinderheilk.,  1913,  sdi,  386. 

2  Zeitschr.  f.  I^nderheilk.,  1913,  viu,  332. 
»Ibid.,  1911,  iii,  441. 

«  Jahrb.  f.  Ivinderheilk.,  1906,  Ixvi,  69. 


46  INFANT  FEEDING 

and  the  digestive  action  of  the  intestine.  There  was  ap- 
parently no  relation  between  nitrogen  retention  and  the 
retention  of  calcium,  and  milk-fat  and  carbohydrates 
might  cause  a  calcium  deficiency,  the  latter  being  less 
active  in  this  respect  than  the  former.  The  amount  of 
calcium  in  the  food  influenced  retention  slightly,  but  ster- 
ilization made  no  difference  whatever. 

The  works  of  Bluhdorn^  and  DuBois  and  Stolte^  show 
that  there  is  a  distinct  relation  between  the  absorption  and 
retention  of  calcium  and  the  reaction  in  the  large  intestines 
and  internal  metabohsm.  Acid  reaction  tends  to  reduce  the 
resorption  and  retention  of  calcium  by  combining  the  cal- 
cium with  the  calcium  phosphate  in  the  bowel.  Alkali  has 
an  opposite  effect. 

In  summing  up  the  calcium  metabolism  of  the  infant 
Orgler'  states  that  the  chief  seat  of  excretion  of  calcium 
is  the  intestines,  that  the  nitrogen  and  calcium  deposits  do 
not  go  parallel  with  one  another,  and  that  the  addition  of  fat 
to  the  food  in  many  cases  distinctly  diminishes  the  calcium 
deposit,  although  in  a  certain  group  of  cases  fat  promotes 
the  retention  of  calcium.  The  addition  of  carbohydrates 
does  not  seem  to  affect  the  retention  of  calcium  adversely. 
In  hunger  conditions  more  calcium  is  excreted  in  the  urine 
and  less  in  the  intestines.  This  is  probably  due  to  the  fact 
that  acids  are  formed  in  the  internal  metabolism  and  that 
calcium  is  used  to  neutralize  these.  He  thinks  that  in  the 
presence  of  soap  stools  the  phosphorus,  which  would  ordi- 
narily be  combined  in  the  intestine,  is  absorbed  in  the  form 

»  Monatsschr.  f.  Kinderheilk.,  1912,  xi,  68. 

2  Jahrb.  f.  Kinderheilk.,  1913,  Ixxvii,  21. 

3  Ergeb.  d.  inn.  Med.  Kinderheilk.,  1912,  viii,  142. 


ABSORPTION    AND    METABOLISM  47 

Oi  phosphoric  acid  and  is  excreted  in  the  urine  as  a  fixed 
alkali.  Cod-liver  oil  increases  calcium  deposit  onl>'  in 
rachitic  cliildren. 

In  their  phy.siologic  effects  on  the  body  the  salts  have 
principally  been  studied  in  relation  to  the  weight  (increase 
or  decrease),  the  temperature,  the  effect  on  the  nervous 
system,  and  the  effect  on  the  white  blood-cells.  Calcium 
in  small  amount  has  little  or  no  action  on  the  weight,  but 
in  large  doses  causes  loss  in  weight.^  As  to  the  action 
of  the  calcium  on  the  temperature,  very  httle  has  been 
found  out,  but  what  has  been  done  would  seem  to  show  that 
the  calcium  is  apyretic  in  its  action  or,  at  times,  may  pro- 
duce subnormal  temperature  even  to  the  point  of  collapse. 
Much  interest  of  late  has  been  taken  in  the  relation  of 
calcium  metabolism  to  tetany  and  other  nervous  condi- 
tions. (The  calcium  metabolism  in  tetany  will  be  discussed 
later.)  As  to  the  action  of  calcium  on  the  child's  nervous 
system,  it  would  seem  to  have  an  inhibiting  effect  on  undue 
nerve  action.  A  very  interesting  series  of  experiments  have 
recently  been  carried  on  by  Neurath-  in  respect  to  the  cal- 
cium in  the  blood  and  its  relation  to  various  conditions  in 
the  infant.  He  used  Wright's  method,  which  estimates 
the  calcium-content  of  the  blood  by  determining  the 
amount  of  ammonium  oxalate  required  to  prevent  blood 
coagulation.  Neurath  found  that  the  amount  of  calcium 
in  the  blood  of  newborn  and  very  young  infants  was  very 
high,  and  remained  higher  than  in  the  adult  throughout 
the  first  year.  Attempts  to  produce  artificially  a  calcium 
increase  in  the  blood  by  introduction  of  more  calcium  in 

1  Schlos8,  Jahrb.  f.  Kinderheilk.,  1910,  Ixxi,  296. 
^Zeitschr.  f.  Kinderheilk.,  1910,  i,  1. 


48  INFANT   FEEDING 

the  food,  as  a  rule,  resulted  not  in  increased,  but  in  distinct 
decreased,  calcium-content  in  the  blood.  In  hunger,  cal- 
cium is  not  excreted  in  increased  amount  through  the  in- 
testines, but  is  to  be  found  in  the  urine  in  larger  quantities. 

To  sum  up,  calcium  tends  to  reduce  temperature  and  to 
quiet  nervous  irritability.  As  to  the  water  retention,  if  it 
acts  at  all,  it  tends  either  to  promote  a  transient  retention 
or  a  distinct  reduction  in  the  quantity  of  water  in  the 
body.  The  calcium-content  of  the  blood  in  infants  is 
greater  than  in  the  adult. 

The  sodium  salts,  especially  of  the  halogen  group,  and 
of  these,  most  often  sodium  chlorid,  have  been  rather  ex- 
tensively studied  as  to  their  physiologic  action.  The  in- 
troduction of  salt  solution  (3  per  cent,  sodium  solution)  by 
mouth^  has  produced  a  distinct  gain  in  weight  if  given  in 
small  quantities  to  normal  children.  If,  however,  it  be 
given  in  larger  amounts  or  to  children  with  gastro-intestinal 
disturbances,  the  result  is  much  more  likely  to  be  a  loss 
of  weight.  The  former  effect  is,  in  aU  probability,  due 
to  the  retention  of  water  with  the  sodium  chlorid;  the 
latter,  to  a  nourishment  disturbance  caused  by  an  excessive 
amount  of  this  salt.  Rises  of  temperature  regularly  occur 
in  normal  breast-fed  infants  after  ingestion  of  3  to  5  ounces 
of  a  3  per  cent,  sodium  chlorid  solution.  The  height  of  the 
fever  course  is  reached  in  about  six  hours,  and  lasts  sixteen 
to  twenty-four  hours.  This  is  not,  as  formerly  supposed,  a 
peculiar  characteristic  of  very  young  babies,  but  is  found 
in  infants  up  to  a  year  and  over.  Berend  and  Tezner^  have 
shown  that  in  these  cases  there  is  a  retention  of  water  and 

^  Nothmann,  Zeitschr.  f .  Kinderheilk.,  1910,  i,  73. 
2  Monatsschr.  f.  Kinderheilk.,  1911,  x,  212. 


AB80RPTI0x\    AND   METABOLISM  49 

salt  in  the  blood,  Schloss  thinks  that  the  "sodium  chlorid 
fever"  is  due  to  the  quick  retention  of  water  in  the  system. 
Katzenellenbogen'  has  shown  that  the  hydropigenous  action 
of  sodium  chlorid  has  no  effect  on  perspiration,  and  thinks 
that  the  sodium  chlorid  fever  produced  by  oral  administra- 
tion depends  on  the  concentration  of  the  solution.  It  has 
been  conclusively  shown  recently  that  the  so-called  sodium 
clilorid  fever  produced  by  subcutaneous  injection  of  physio- 
logic salt  solution  is  not  due  to  the  salt,  but  to  some  ele- 
ment contained  in  the  distilled  water,  since  when  the  water 
was  freshly  distilled  no  fever  resulted  (Samelson,^  BendLx, 
and  Bergmann^).  Sodium  would  seem  to  have  little  effect 
on  the  nervous  system  except,  perhaps,  in  spasmophilia. 
It  is  interesting,  however,  that  Nothmann  has  noted  a  dis- 
tinct exaggeration  of  the  deep  reflexes  in  his  case  of  "sodium 
chlorid  intoxication."  As  to  the  effect  of  the  sodium  chlorid 
on  the  blood,  Rosenstern^  could  produce  no  leukocjlosis 
by  giving  a  1  per  cent,  solution  of  sodium  chlorid  by  mouth 
to  normal  children,  but  in  children  '^ith  a  gastro-intestinal 
disturbance  there  was  produced  a  poh-nuclear  leukocytosis 
along  with  the  rise  in  temperature. 

In  summing  up,  then,  we  see  that  sodium  promotes  water 
retention,  produces  rise  in  temperature,  increases  the  ner- 
vous irritability,  and  tends  to  the  production  of  a  leuko- 
cytosis. 

Potassium  has  been  less  thoroughly  studied,  but  is  not 
so  active  as  sodium.  It  produces  only  transient  water  re- 
tention, and  rarely  causes  rise  in  temperature. 

1  Monatsschr.  f.  Kinderheilk.,  1911,  x,  465. 

2  Ibid.,  1912,  xi  (Orig.),  125. 

3  Ibid.,  1912,  xi  (Orig.),  387. 
*  Ibid.,  1909,  viii,  9. 

4 


50  INFANT   FEEDING 

Of  the  action  of  magne-mim,  little  is  known.  In  general, 
it  seems  to  be  very  similar  to  that  of  calcium.  Birk^ 
studied  the  metabolism  of  magnesium,  and  found  that 
whole  milk  nourishment  gave  negative  magnesium  balance, 
while  carbohydrates  favor  its  retention,  as  does  fat-poor 
food. 

Meyer,*  after  a  careful  study  of  the  action  of  the  various 
salts  on  the  infant  metaboMsm,  finds  that  there  is  a  paral- 
lehsm  between  loss  of  weight  and  deminerahzation,  and 
that  salts  that  produce  the  former  produce  the  latter. 
He  can  demonstrate  no  specific  action  of  calcium  and  po- 
tassium, but  at  present  must  regard  the  sodium  action  as 
specific. 

The  fate  of  phosphorus  in  the  organism  is  of  much  import- 
ance :  first,  because  of  the  entrance  of  this  into  the  formation 
of  the  protein  molecule,  and,  second,  because  of  the  phos- 
phorus present  in  bone.  The  absorption  of  phosphorus 
varies  in  wide  boundaries,  and  is  httle  if  at  all  dependent 
on  the  amount  of  phosphorus  in  the  food. 

Its  absorption  is  perhaps  favored  by  certain  fat  foods,  as 
cod-fiver  oil,  but  this  seems  to  be  dependent  on  the  pres- 
ence of  rickets.  According  to  MoU,^  well  breast-fed  infants 
have  not  phosphorus  in  the  urine  in  sufficient  quantity  to 
estimate  by  our  present  methods.  Langstein  and  Niemann,* 
in  examining  the  urine  of  newborn  breast-fed  infants, 
found  that  httle  phosphorus  was  present  on  the  first  day  of 
fife,  that  a  steadily  increasing  amount  appeared  from  the 
second  to  the  seventh  day,  and  that  there  was  a  decrease 

1  Jahrb.  f.  Kinderheilk.,  1906,  bn-i,  300. 
^Zeitschr.  f.  Kinderheilk.,  1911,  ii,  360. 
3  Jahrb.  f .  Kinderheilk.,  1909,  Ixix,-  129,  304,  450. 
*  Ibid.,  1910,  Ixxi,  604. 


ABSORPTION    AND    METABOLISM  51 

then  to  the  twelfth  day,  but  that  even  then  an  appreciable 
amount  remained. 

Sulphur  occurs  in  the  urine  in  the  form  of  acid  or  neutral 
sulphur.  The  amount  of  acid  sulphur  is  subject  to  great 
variations,  dependent  upon  the  protein-content  of  the 
food.i  The  neutral  sulphur  is  not  affected  by  the  amount 
of  protein  or  carbohydrates  in  the  food,  but  an  increase  in 
the  food-fat-content  causes  marked  increase  in  the  neutral 
sulphur  in  the  urine.  Tobler^  explains  this  on  Freund's 
theory  that  the  neutral  sulphur  in  the  urine  is  a  derivation 
of  the  bile,  and  that  on  nourishment  rich  in  fat  the  flow  of 
bile  is  increased.  Freund  thinks  that  the  reason  for  the 
increased  amount  of  neutral  sulphur  in  the  urine  of  children 
with  gastro-intestinal  disturbance  is  the  destructive  pro- 
cesses in  the  liver.  Hunger  reduces  the  amount  of  neutral 
sulphur  in  the  urine  to  a  minimum. 

Of  the  halogen  group,  the  chlorin  is  the  only  one  to  be 
considered  in  this  connection.  The  effects  of  sodium, 
potassium,  and  calcium  are  practically  all  obtained  with 
the  halogen  derivatives  (hence  chlorin).  The  absorption 
of  chlorin  depends,  to  a  great  extent,  upon  the  stool.  In 
the  watery  stool  the  water  is  excreted  with  a  salt  (especially 
sodium  chlorid),  hence  the  absorption  of  chlorin  is  poor. 

In  regard  to  the  water  retention  ]Meyer^  has  discovered  three 
classes  of  cases:  First,  those  in  which  there  was  a  decrease 
in  weight  when  the  food  was  concentrated  and  the  weight 
increased  only  after  the  addition  of  water;  second,  those 
where  the  weight  remained  the  same  on  a  concentrated  food 

1  Freund,  Zeitschr.  f.  Phys.  Chem.,  1900,  xxLx,  24. 

2  Verhandl.  d.  Gesellsch.  f.  Kinderheilk.,  1909,  94. 
» Zeitschr.  f.  Kinderheilk.,  1912,  v,  1. 


52  INFANT   FEEDING 

and  there  was  an  increase  after  the  addition  of  water;  and, 
third,  those  in  which  the  addition  of  water  made  no  difference, 
but  who  did  well  on  a  concentrated  food.  He  found  that  the 
water  need  decreased  with  increasing  age;  that  on  artificial 
food  the  water  need  was  89  grams  per  kilo  weight  in  twenty- 
four  hours  at  the  beginning  and  80  at  the  end  of  the  first 
year,  while  in  breast-fed  infants  the  water  need  amounted 
to  134  to  140  grams. 

A  few  words  may  not  be  amiss  here  in  regard  to  acidosis. 
The  alkahs  in  the  feces  are  increased  when  the  fat-content 
of  the  food  is  high,  possibly  due  to  an  increased  excretion 
of  the  alkaUs  in  the  formation  of  soap  in  the  intestinal 
canal.  There  exists  in  the  infant  a  marked  tendency  to- 
ward acidosis,  as  is  manifested  by  the  frequent  appearance 
of  increased  amounts  of  ammonia  in  the  urine.  In  all 
probabiUty  this  acidosis  in  many  cases  is  not  so  much  a 
true  increase  of  the  amount  of  acid  in  the  system,  as  a 
disturbance  of  the  acid  alkah  equihbrium  by  the  with- 
drawal of  the  alkahs  through  the  intestinal  wall. 


CHAPTER  V 

BACTERIOLOGY  OF  THE  G  ASTRO -INTESTINAL  TRACT 
OF  THE  HEALTHY  INFANT 

The  bacteria  found  in  the  alimentary  canal  of  the  normal 
infant  may  be  divided  into  two  distinct  classes:  the  essen- 
tial organisms  and  the  accidental.  The  latter  are  such  as 
are  introduced  with  the  food  or  some  foreign  substance,  as 
air,  and  which  are  to  be  found  usually  only  in  small  quan- 
tities more  or  less  throughout  the  gastro-intestinal  canal 
and  perhaps  even  in  the  feces.  Their  presence  in  the  lower 
bowel  goes  to  show  that  the  alimentary  canal  does  not 
produce  antiseptic  substance  of  sufficient  power  to  kill  all 
bacteria,  even  though  these  may  be  introduced  into  the 
mouth  and  pass  the  entire  length  of  the  canal. 

Distribution  of  Bacteria. — Bacteria  are  to  be  found  in 
the  mouth  immediately  after  birth,  and  within  a  very  short 
time  thereafter  in  the  rectum.  The  probabilities  are  that 
the  invasion  takes  place  in  both  directions,  since  thirty-six 
hours  after  birth  bacteria  have  been  found  in  the  jejunum 
and  ileum,  even  though  none  were  to  be  found  in  the 
duodenum. 

Of  course,  the  bacterial  flora  of  the  mouth  is  a  more  or 
less  varied  one.  In  the  newborn  infant  arc  found  the 
Bacillus  coli,  the  enterococcus,  and  Bacillus  perfringcns. 
Later,  the  streptococcus  and  pneumococcus  are  frequently 

53 


54  INFANT   FEEDING 

found,  and  after  the  teeth  appear,  the  fusiform  bacteria. 
The  flora  of  the  mouth  in  incubator  babies  is  richer,  due, 
no  doubt,  to  the  more  favorable  temperature. 

The  stomach  is,  as  a  rule,  poor  in  bacteria,  but  should 
such  enter  in  large  quantities  with  the  food,  the  antiseptic 
action  of  the  gastric  juice  may  not  be  sufficiently  strong  to 
destroy  them.  A  most  fertile  source  of  infection  below  the 
stomach,  as  a  result  of  the  inability  of  this  organ  to  sterilize 
its  contents,  is  seen  in  the  large,  hard  milk-clot,  in  the 
center  of  which  bacteria  can  be  included  and  thus  earned 
into  the  intestines. 

The  bacterial  flora  varies  greatly  in  the  small  intestine, 
both  as  to  quantity  and  quality.  From  the  duodenum 
only  an  occasional  colony  can  be  grown,  while  in  the  ileum 
bacteria  are  present  in  large  numbers.  The  reasons  for  the 
smaU  number  of  bacteria  to  be  found  in  the  duodenum  are 
many.  In  the  first  place  the  secretion  is  sterile  and  is 
mixed  with  a  food-content  which  has  already  undergone 
the  antiseptic  action  of  the  gastric  juice;  again,  the  food 
remains  too  short  a  time  in  the  duodenum  for  bacterial 
growth;  and,  again,  the  intestinal  secretion  itself  is  bacte- 
ricidal in  its  action. 

All  investigators  agree  that  the  lactic  acid  bacillus  and 
the  colon  bacillus  are  common  inhabitants  of  the  small 
intestine.  Sittler,  however,  thinks  that  the  enterococcus 
(Streptococcus  acidi  lactici)  is  found  in  greater  quantities 
than  either  of  the  others.  This  would  seem  to  make  very 
little  difference  so  far  as  their  action  on  the  food  is  con- 
cerned. The  ileocecal  valve  seems  to  mark  a  distinct  divid- 
ing line  of  the  bacterial  flora,  because  in  the  cecum  the 
number  of  bacteria  is  markedly  increased,  and  we  here 


BACTERIOLOGY    OF  THE    CASTRO-INTESTINAL  TRACT      55 

encounter  for  the  first  time  tiie  anal-roijic  Bacillus  bifidus 
communis,  which  organism  forms  the  chief  bacterium  found 
in  the  breast-fed  infant's  stool;  in  fact,  it  occurs  there 
almost  to  the  exclusion  of  other  bacteria.  The  lactic  acid 
and  colon  bacilli  progressively  decrease  in  number  as  the 
rectum  is  approached.  According  to  Sittler,  there  is  found 
in  the  mucus  throughout  the  intestine  the  Bacillus  per- 
fringens.  INIoro  has  found  the  Bacillus  acidophilus  to  be 
quite  constant  in  the  small  intestine  and  the  upper  part 
of  the  large  intestine  (with  this  the  Bacillus  exilis  is  prob- 
ably identical).  Staphylococci,  the  motile  butyric  acid 
bacillus,  intestinal  diplococci,  and  the  Bacillus  mesentericus 
vulgatus  are  also  frequently  found.  MetchnikoflF  also 
regards  the  Bacillus  putrificus  as  a  bacterium  commonly 
found  in  the  intestines  and  feces. 

Although  the  biologic  characteristics  of  bacteria  on 
culture-media  may  not  be  translated  in  toto  to  those  within 
the  body,  still  a  general  idea  of  their  action  can  probably  be 
so  obtained. 

A  brief  resum^  of  the  general  characteristics  of  the  more 
common  intestinal  bacteria  would,  therefore,  be  of  some 
interest. 

The  Bacillus  bifidus  communis  (Tissier)  is  an  obligate 
anaerobic  bacterium,  grown  best  on  sugar-agar.  The  form 
is  polymorphous,  giving  rod  shapes,  rod  shapes  with 
branched  ends,  which  may  or  may  not  be  nodular,  contain- 
ing spores.  Sometimes  the  bodies  stain  irregularly,  show- 
ing irregular  areas  staining  deeply  (Gram  positive),  en- 
closed in  an  almost  clear  or  slightly  staining  body  (Gram 
negative).  Occasionally  we  see  forms  having  small  dee{> 
staining   areas  with    large,    bulging,    non-staining    body, 


56  INFANT   FEEDING 

which  retracts  when  in  salt  solution  (Moro).  (Formes 
vesiculeuses,  Tissier.) 

The  bacillus  has  a  slow,  gliding  movement.  It  grows 
best  on  sugar-agar,  but  is  also  to  be  cultivated  on  sugar- 
bouillon.  No  growth  on  gelatin.  It  does  not  change 
milk,  nor  is  it  pathogenic  to  animals.  It  is  supposed  to 
have  a  certain  putrefactive  action  and  to  grow  best  in  a 
strong  acid-medium  (e.  g.,  in  the  colon  of  the  breast-fed 
infant). 

The  BaciUus  coli  and  B.  lactis  aerogenes  belong  to  the 
same  group.  Their  action  is  largely  the  formation  of  lactic 
acid,  some  strains  of  the  colon  baciUus  forming  indol  in 
bouillon  culture.  Other  characteristics  of  these  bacteria 
are  so  weU  known  that  it  is  useless  to  repeat  them  here. 
The  enterococcus  (Micrococcus  ovalis,  Streptococcus  acidi 
lactici)  is  a  Gram-positive  coccus,  whose  action  on  milk- 
sugar  is  greater  than  that  of  the  Bacillus  lactis  aerogenes. 

The  Bacillus  perfringens  (anaerobic  butyric  acid  bacil- 
lus), as  previously  stated,  is  found  especially  in  the  mucus 
of  the  intestinal  wall.  It  is  found  there  always  in  its  spo- 
rogenous  state,  sometimes  in  its  asporogenous  form.  In 
the  former  state  this  organism  produces  putrefaction,  while 
in  the  latter  it  splits  the  carbohydrates  into  lactic  and 
butyric  acids,  carbon  dioxid,  water,  and  small  quantities 
of  alcohol.  The  Bacillus  putrificus,  which  probably  be- 
longs to  the  same  group  as  the  above,  produces  putrefaction 
in  albumin  media.  The  Bacillus  acidophilus  has  the  pecu- 
liar property  of  growing  on  a  highly  acid  medium  (sufficient 
acid  to  neutralize  like  quantities  of  "5  KoH),  independent 
of  whether  the  acid  is  mineral  or  organic.  It  possesses 
the   power  to   coagulate   cows',  but   not  woman's,  milk. 


PI  A  IE  I 


.Stuiiiin^i  clianict  eristics  of  (he  inlaiil 's  stool  (.,  ItiOD).  Stool  of  the 
breast-fed  infant  Uram  i)ositiv{>;  stool  of  artificially  led  infant  (iraui 
negative. 


BACTERIOLOGY   OF   THE   GASTRO-LNTESTINAL  TRACT      57 

The  Bacillus  acidophilus  is  probably  rather  a  group  of 
bacteria  than  a  single  organism. 

In  the  stool  of  the  normal  breast-fed  child  the  bacteria 
may  form  as  high  as  30  per  cent,  of  the  dry  residue.  Most 
of  these  organisms,  of  course,  are  dead,  but  it  has  been  im- 
possible to  determine  the  exact  proportion  of  dead  to  living 
because  of  the  different  characteristics  in  culture. 

On  the  smear  the  breast  stool  is  found  to  contain  a  bac- 
terial flora,  which  is  almost  altogether  Gram  positive  (due, 
of  course,  to  the  Bacillus  bifidus  communis),  with  here  and 
there  a  Gram-negative  bacillus  or  a  Gram-positive  coccus.^ 
A  peculiarly  interesting  fact  is  that  the  stool  of  the  arti- 
ficially fed  infant  is  almost  sure  to  be  Gram  negative,  while 
that  of  a  baby  on  mixed  feedings  \^'ill  show  gradations 
between  the  two.  After  thorough  investigations  Bahrdt 
and  Beifeld-  advance  the  following  very  plausible  theoiy 
in  explanation  of  these  facts :  On  mothers'  milk  fermentative 
processes  predominate,  while  on  cows'  milk  putrefaction 
is  stronger.  The  calcium-content  and  the  curd  in  cows' 
milk  offer  more  opportunity  for  putrefaction,  hence  the 
lactic  acid  production  from  the  milk-sugar  is  not  so  great. 
In  mothers'  milk  the  lactic  acid  production  is  so  great  as 
to  inhibit  the  gro^^ih  of  the  Bacillus  coli  and  B.  lactis 
aerogenes  (enterococcus  (?))  in  the  lower  end  of  the  ileum, 

^  A  very  satisfactory  stain  is  Escherich's  modification  of  Weigert's. 
Solutions:  (a)  Gentian-violet  5:200,  boil  one-half  hour  and  filter. 
(6)  Alcohol;  anilin  oil  11:3,  mix  a  and  b  in  proportion  of  17:  3.  Tech- 
nic:  Spread  thin  and  fix  in  flame  gentian-violet  solution  for  a  min- 
ute, remove  wnth  filter-paper,  pour  on  Lugol's  solution,  and  pour 
off  quickly,  decolorize  with  anilin-xylol  until  no  blue  color  remains, 
cover  with  xylol,  and  dry.  Counterstain  with  concentrated  alcoholic 
solution  of  fuchsin,  wash  in  water,  dry,  and  examine. 

=  Jahrb.  f.  Kinderheilk.,  1910,  Ixxii,  Erganzungsheft,  71. 


58  INFANT   FEEDING 

while  the  highly  acid  medium  favors  the  growth  of  the 
Bacillus  bifidus  communis  and  the  acidophile  bacteria. 

In  the  human  intestinal  tract  two  antagonistic  bacterial 
processes  are  active:  fermentation  and  putrefaction. 

In  the  normal  breast-fed  infant  the  former  predominates 
to  a  much  greater  degree  than  in  the  normal  artificially- 
fed  infant.  Fermentation  is  present  in  an  acid  medium, 
and  is,  in  all  probability,  due  to  the  action  of  the  Bacillus 
lactis  aerogenes,  B.  coli,  enterococcus,  etc.  In  the  acid 
medium  formed  by  these  bacteria  there  thrive  the  Bacillus 
bifidus  communis  and  the  B.  acidophilus.  The  former  of 
these  at  least  has  a  putrefactive  action,  so  that  if  there  is 
any  putrefaction  in  the  normal  infant's  intestines  it  must 
take  place  in  the  colon. 

On  the  other  hand,  we  have  to  reckon  with  the  Bacillus 
perfringens,  that  inhabitant  of  the  mucus  which,  in  its 
sporogenous  form,  is  putrefactive  in  its  action,  and  in  its 
asporogenous,  fermentative,  but  which  is  found  in  the  in- 
testines mostly  in  its  sporogenous  form. 

One  would  conclude  ordinarily  that,  given  a  food  rich 
in  carbohydrates,  the  pathologic  result,  if  any,  would  nat- 
urally be  an  excess  of  fermentation,  but  is  this  so?  The 
mucus  of  the  gastro-intestinal  tract  is,  in  all  probability, 
the  protein  from  which  putrefactive  products  are  formed. 
This  being  true,  anything  which  increases  the  flow  of  the 
mucus  not  only  gives  a  medium  in  which  putrefactive 
bacteria  can  work,  but  also  increases  the  alkahnity  (de- 
creases the  acidity)  of  the  intestinal  content.  If  the 
products  of  fermentation  are  so  irritating  to  the  mucus 
membrane  as  to  cause  an  increased  flow  of  mucus,  or  if  the 
metabolic   products   of  excessive   carbohydrate   digestion 


BACTERIOLOGY    OF   THE    GASTRO-INTESTINAL   TRACT      59 

cause  an  increased  excretion  (especially  of  alkalis)  through 
the  intestinal  wall,  the  result  is  very  likely  to  be  an  increase 
of  putrefactive  processes  which  may  doniinate  the  fermenta- 
tion. This,  of  course,  is  largely  problematic,  but  it  offers 
a  theory  which  readily  explains  those  cases  in  which  are 
found  putrefactive  stools,  although  the  gastro-intcstinal 
disturbance  is  palpably  due  to  an  excess  of  carbohydrates 
in  the  food. 

As  to  the  source  of  putrefaction — i.  e.,  as  to  whether  this 
is  due  to  decomposition  of  the  food  protein  or  the  mucus — 
some  discussion  may  be  raised,  but  suffice  it  so  say  that  clin- 
ically, in  a  strongly  protein  diet  (casein),  very  little  if  any 
putrefaction  is  recognizable,  and  on  addition  of  protein  to 
the  food  there  is  no  increase  of  putrefactive  products  in  the 
stool  or  urine. 


CHAPTER  VI 

ATTRIBUTES   OF   THE   NORMAL   CHILD 

To  be  able  to  judge  the  ill  effects  of  certain  foods  upon 
the  infant  organism  it  is  first  necessary  to  be  able  to  judge 
accurately  of  any  variations  from  the  normal.  This  neces- 
sitates a  comprehensive  and  detailed  knowledge  of  what 
constitutes  the  normal.  If  for  no  other  reason  than  as  a 
prophylactic  measure,  the  first  symptoms  of  disturbance 
should  be  recognized.  The  tendency  to  disregard  slight 
gastro-intestinal  symptoms  is  so  widespread  that  one  feels 
helpless  in  endeavoring  to  caution  even  the  profession  in 
this  regard,  but  the  recognition  and  proper  treatment  of 
shght  gastro-intestinal  disturbance  is  of  much  more  import- 
ance than  the  abihty  to  treat  more  severe  conditions  when 
they  arise. 

Of  all  things  in  connection  with  the  infant,  none  is  more 
useful  and  none  so  abused  as  the  weight  if  taken  at  a 
given  time  or  in  the  form  of  a  weight-curve.  As  one  sign 
of  progress  in  the  infant,  gain  in  weight  is  invaluable,  as 
the  only  sign,  it  is  to  be  avoided.  To  regard  a  gain  in 
weight  as  the  only  sign  of  progress  is  to-day  the  most  vital 
error  that  is  made.  The  attempt  to  produce  it  by  giving 
more  food  to  the  infant  causes  more  fatahties  than  do 
bacteria  and  hot  weather  combined. 

At  birth  the  average  normal  infant  weighs  from  7  to  8 
pounds:  the  girl  baby  about  7  to  7^  pounds;  the   boy, 

60 


ATTRIBUTES   OF  THE   NORMAL   CHILD  61 

7i  to  8  pounds.  However,  a  child  may  weigh  as  little  as 
5  pounds  or  as  much  as  12  at  birth  and  still  be  perfectly 
normal.  The  initial  loss  in  weight  occurs  in  the  first  few 
days,  usually  the  low  mark  being  recorded  on  the  third  to 
the  fifth  day,  after  which  time  the  babies  begin  to  gain,  and 
normally  reach  the  original  weight  on  the  tenth  to  the  four- 
teenth day.  The  usual  total  loss  amounts  to  from  (i  to  8 
ounces,  but  varies  in  wide  boundaries,  being  as  little  as  2 
to  3  ounces  and  as  high  as  1  pound.  More  than  1  pound  loss, 
especially  in  a  small  infant,  should  be  regarded  as  of  patho- 
logic character,  and  conditions  should  be  carefully  investi- 
gated in  order  to  determine  the  cause.  Other  things  being 
equal,  a  fat  baby  is  more  likely  to  lose  a  large  amount  of 
weight  than  a  thin  one,  and  large  losses  in  thin  babies  are, 
consequently,  more  likely  to  indicate  pathologic  conditions. 
As  to  the  cause  of  the  initial  loss  in  weight,  many  theories 
are  advanced.  We  must,  of  course,  recognize  that  the  loss 
of  meconium  and  the  fact  that  the  child  received  insufficient 
food  for  the  first  few  days  of  life  may  account  for  this 
condition,  but  to  determine  what  body  constituents  go 
to  make  up  the  loss  careful  experimentation  is  necessary. 
Hirsch^  thinks  that  the  total  loss  can  be  accounted  for 
by  the  weight  of  the  meconium.  Even  if  this  be  true,  we 
must  yet  account  for  some  body  waste  which  perhaps  the 
meconium  contains.  Langstein  and  Niemann  found  a  dis- 
tinct nitrogen  deficiency,  but  this  was  not  so  great  as  to 
suggest  that  destruction  of  the  body  proteins  and  their 
excretion  would  account  for  the  total  loss  in  weight.  A 
much  more  plausible  conclusion  is  that  reached  by  Rott," 

1  Ref.  MonatsBchr.  f.  Kinderheilk.,  1910,  ix  (Ref.  2.) 
» Zeitschr.  f.  Kinderheilk.,  1910,  i,  43. 


62  INFANT   FEEDING 

who,  after  estimation  of  the  water-content  of  the  blood  in 
the  newborn,  comes  to  the  conclusion  that  the  initial  loss 
is  a  loss  of  water  (together  with  salts),  and  is  due,  probably 
in  large  part,  to  the  fact  that  these  babies  receive  little  fluid 
in  any  form.  Birk^  agrees  in  the  main  with  Rott.  Mensi^ 
finds  no  relation  between  icterus  neonatorum  and  the  physi- 
ologic weight  decrease. 

After  the  initial  loss  and  return  to  the  original  weight, 
the  normal  breast-fed  infant  will  increase  more  rapidly  in 
the  first  half  than  in  the  second  half  of  the  first  year.  The 
gain  in  the  first  six  months  should  be  6  to  8  ounces  a  week, 
while  from  the  sixth  to  the  twelfth  month  the  gain  should 
not  be  more  than  2  to  3  ounces,  so  that  at  the  end  of  the 
first  year  the  weight  is  about  1  pound  a  month  or  12  pounds' 
gain  since  birth.  I  reahze  that  this  may  seem  very  con- 
servative to  many,  but  it  has  been  the  experience  of  the 
writer  that,  almost  without  exception,  the  baby  who  is 
extremely  fat  at  the  end  of  the  first  year  suffers  from  attacks 
of  gastro-intestinal  disturbance  during  the  second  to  pay 
for  the  overtaxing  of  the  digestive  functions  in  the  previous 
months  of  life. 

.  The  question  of  the  normal  weight  from  birth  on  in  the 
artificially  fed  infant  is  an  open  one.  To  feed  a  child  from 
birth  on  and  have  it  gain  steadily  and  be  free  from  gastro- 
intestinal disturbance  is  much  more  uncommon  than  we  or- 
dinarily suppose.  To  judge  of  the  normality  of  a  child  arti- 
ficially or  breast  fed,  observation  of  a  few  weeks  is  not  suflB- 
cient.  There  is  a  steadily  increasing  tendencj^  on  the  part 
of  physicians  to  confine  their  efforts  in  artificial  feeding 

1  Monatsschr.  f .  Kinderheilk.,  1910,  ix  (Orig.),  505. 

2  La  Pediatria,  1912,  x,  641. 


ATTRIBUTES    OF    THE    NORMAL    CHILD 


63 


in  the  first  weeks  of  life  to  the  maintenance  of  a  normal 
gastro-intestinal  tract  and  pay  little  attention  to  the  weight. 
Certain  it  is  that  any  marked  gain  in  the  first  few  weeks  of 


Fig.  3. — A,  The  ideal  weight-curve  of  a  normal  breast-fed  infant 
(schematic);  B,  the  ideal  weight-curve  of  an  artificially  fed  infant 
(schematic);  C,  the  more  usual  weight-curve  of  the  infant  fed  ar- 
tificially and  showing  no  gastro-intestinal  symptoms  (schematic). 

life  in  the  child  fed  artificially  is  usually  followed  by  severe 
disturbance  and  resulting  marasmus.  If  we  are  to  regard 
the  weight-curve  of  the  breast-fed  infant  as  the  ideal  stand- 


64  INFANT   FEEDING 

ard  by  which  to  judge  the  artificially  fed,  we  may  be  sure 
that  we  will  have  few  normal  artificially  fed  infants. 

Perhaps  if  we  modify  this  by  saying  that  at  the  end  of  the 
first  year  the  weights  should  be  the  same,  we  may  find  more 
infants  to  the  measure.  The  steady  gain  of  4  ounces  a 
week  during  the  whole  of  the  first  year  is  the  best  which  we 
can  hope  to  procure  in  the  artificially  fed  infant,  and  this  only 
when  all  other  conditions  are  normal.  A  gain  of  8  ounces 
in  a  week  should  always  make  us  apprehensive,  because 
almost  invariably  such  an  excessive  gain  in  weight  is  fol- 
lowed by  a  catastrophe.  (This  does  not  hold  true  for  in- 
fants convalescent  from  severe  dehydrating  intestinal  dis- 
turbances.) The  gain  in  weight  during  the  second  year  is 
very  small.  Weekly  weighings  will  sometimes  show  a  differ- 
ence of  1  to  2  ounces.  It  is  not  at  all  unusual,  however, 
to  have  a  perfectly  normal  infant  go  for  several  weeks  dur- 
ing the  second  year  without  gain  in  weight. 

The  length  of  the  newborn  baby  averages  about  20  inches 
(50  cm.),  and  at  the  end  of  the  first  year,  29  to  30  inches 
(72-75  cm.).  At  the  beginning  of  the  fifth  year  the  birth 
length  should  be  about  doubled.  Variations  in  length 
growth  are  not  great,  no  matter  what  the  state  of  nutrition 
of  the  chUd.  There  seems  to  be  comparatively  Httle  hin- 
drance to  length  growth  even  in  severe  marantic  con- 
ditions. 

It  is  very  important  to  recognize  the  fact  that  there  is 
a  distinctly  normal  temperature  variation  for  the  infant, 
and  that  any  excursions  above  or  below  this  mean  are  ab- 
normal, and  are  frequently  associated  with  nourishment 
disturbances.  The  rectal  temperature  in  the  infant  corre- 
sponds to  the  oral  temperature  in  the  adult,  i.  e.,  a  tempera- 


ATTRIBUTES   OF   THE    NORMAL   CHILD  05 

ture  of  98.6°  F.  is  considered  the  normal  mean  in  both 
instances.  The  temperature  by  rectum  is  the  only  sure 
one  to  employ  in  infants,  and  hence  no  reference  will  Ixj 
made  to  other  methods  of  temperature  registration  in 
this  work. 

The  variation  in  the  normal  infant  should  be  no  greater 
than  from  98.2°  to  99°  F.  It  might  be  mentioned  here  that 
subnormal  temperature  is  frequently  of  great  significance. 
In  rare  cases  premature  or  marantic  infants  may  react  to 
infections  with  markedly  subnormal  temperature. 

The  pulse-rate  is  to  the  respiration-rate  as  4  to  1.  The 
pulse  in  the  newborn  is  about  120  per  minute,  and  remains 
well  above  100  during  the  first  year  of  life.  The  impulse  is 
variable,  both  as  to  rate  and  volume,  due  to  the  irritability 
of  the  heart  at  this  age.  A  slowing  is  as  much  a  variation 
from  the  normal  as  an  acceleration.  Both  pulse  and  respi- 
ration rate  should  be  taken  only  when  the  infant  is  quiet. 

The  respiration-rate  in  the  infant  is  25  to  30  per  minute. 
The  type  of  respiration  is  almost  wholly  diaphragmatic, 
due  to  the  fact  that  the  ribs  form  almost  a  right  angle  with 
the  vertebral  column,  holding  the  sternum  high  up  and 
giving  the  chest  a  greater  anteroposterior  diameter.  As 
a  consequence  of  the  type  of  breathing  and  the  slight  ability 
on  the  part  of  the  body  to  aid  respiration  by  the  use  of  the 
accessory  respiration  muscles,  marked  variations  in  respira- 
tion-rate are  to  be  noted  with  comparatively  slight  disturb- 
ances. This  is  particularly  true  in  abdominal  conditions 
where  the  action  of  the  diaphragm  is  impeded. 

The  skin  at  birth  is  apt  to  be  very  red,  often  showing 
distinct  desquamation  for  several  days.  After  the  first 
week,   provided   no   icterus   neonatorum   be   present,   this 


66  INFANT   FEEDING 

intense  red  gives  place  to  a  pale  rose-pink.  No  abrasion 
or  eruptions  of  any  sort  are  to  be  found  on  the  healthy- 
infant's  skin,  and  any  such  should  lead  us  to  search  for  the 
cause.  As  we  will  see  later  (Exudative  Diathesis),  even  the 
fine,  grayish-yellow  scales  found  on  the  scalp  in  the  region 
of  the  anterior  fontanel  are  to  be  regarded  as  pathologic. 
The  cheeks  of  the  young  infant  are  not  normally  red,  but 
are  found  so  only  in  the  flush  of  fever,  in  the  early  stages  of 
a  facial  eczema,  or  after  exposure  to  cold  air. 

The  subcutaneous  tissue  should  feel  firm;  perhaps  the 
vulgar  term  ''  sohd  "  will  be  more  readily  comprehended. 
Flabbiness  or  hardness  without  elasticity  is  not  to  be  seen 
in  the  perfectly  normal  infant.  In  the  following  pages  the 
state  of  the  subcutaneous  tissue  will  be  referred  to  as  the 
tissue  turgor,  the  tendency  to  flabbiness  as  reduced  tissue 
turgor,  and  the  hard  inelastic  edematous  condition  as 
increased  tissue  turgor. 

According  to  most  observers,  in  the  normal  infant  the 
inguinal  glands  are  the  only  lymphatic  glands  which  are 
palpable.  These  can  practically  always  be  felt  as  small 
masses  the  size  of  a  pin's  head  or  somewhat  larger. 

T\Tiether  we  may  regard  enlargement  of  the  axillary  and 
supracondylar  glands  as  normal  seems  at  least  veiy  doubt- 
ful. Enlargement  of  the  cervical  glands  is  sufficiently 
often  the  result  of  pharyngeal  infection  as  to  lead  us  to 
suspect  this  in  every  case. 

Owing  to  the  lack  of  calcification,  the  hones  in  infancy 
are  very  elastic.  The. anterior  fontanel  does  not  close 
before  the  twelfth  to  sbcteenth  month,  but  under  normal 
conditions  should  not  remain  open  after  the  eighteenth 
month.    Just  after  birth  and  for  the  first  few  weeks  there 


ATTRIBUTES    OF    THE    NORMAL    CHILD  G7 

is  a  slight  bulfjing  at  the  costochondral  junction;  as  a  rule 
this  disappears  during  the  second  month.  Soft  spots  in 
the  skull,  especially  in  the  temporal  and  occipital  bones, 
and  softness  of  the  bones  along  the  sutures,  is  frequently 
found  in  newborn  infants;  these  disappear  during  the  second 
month  and  are  in  no  way  indicative  of  rickets  (Wicland).^ 
Kassowitz'^  strongly  opposes  this  interpretation  of  Wieland's 
findings. 

The  teeth  begin  to  appear  usually  about  the  sixth  month, 
and  average  one  a  month  thereafter.  Should  the  first 
tooth  appear  as  early  as  the  fifth  month  or  as  late  as  the 
eighth,  one  could  scarcely  regard  the  condition  as  patho- 
logic. However,  if  its  appearance  is  delayed  until  after 
the  first  year  or  even  to  the  eleventh  or  twelfth  month, 
there  is  usually  some  underlying  cause,  such  as  rickets  or 
syphilis.  The  first  tooth  to  appear  is  usually  an  upper  or 
a  lower  incisor.  This  is  most  often  followed  by  the  other 
upper  or  lower  incisor  and  then  by  teeth  in  the  opposite 
jaw.  The  symptoms  accompanying  the  eruption  of  the 
teeth  arc,  at  the  most,  pain  and  increased  flow  of  salivary 
secretion.  One  cannot  too  strongly  deny  the  repeated 
assertion  that  "  cutting  teeth  "  causes  diarrheas,  convul- 
sions, etc.  One  must  suspect  that  the  physician  who  makes 
this  assertion  is  blindly  endeavoring  to  veil  his  ignorance. 
Neither  in  science  nor  clinical  experience  is  there  any  reason 
whatsoever  to  connect  the  eruption  of  the  teeth  etiologically 
with  these  diseased  conditions. 

The  murine  of  the  normal  infant  is  light  yellow  in  color, 
of  slightly  acid  reaction,  specific  gravity,  1.005.     It  con- 

1  Jahrb.  f.  Kinderheilk.,  1909,  Ixx,  539. 

2  Ibid.,  1912,  Ixwii,  369. 


68  IXFAXT    FEEDING 

tains  no  albumin  or  sugar,  and  at  most  in  the  sediment  are 
found  a  few  leukoc}i;es  and  epithelial  cells.  In  the  newborn, 
even  under  normal  conditions,  most  writers  on  the  subject 
agree  that  albumin  may  be  transiently  present.  The 
exact  cause  of  this  has  not  yet  been  determined.  Uric-acid 
crystals  are  also  found  rather  frequently  in  the  first  days 
after  birth,  due  to  uric-acid  infarcts  of  the  kidneys.  The 
quantity  of  urine  passed  in  twenty-four  hours  varies  greatly 
with  the  age  of  the  child  and  the  composition  of  the  food. 
In  the  newborn  infant  on  the  first  or  second  day  this 
amounts  to  about  50  c.c,  and  increases  rapidly,  so  that 
from  the  tenth  to  the  fortieth  day  the  twenty-four-hour 
excretion  is  200  to  250  c.c.  By  the  end  of  the  first  year 
the  daily  excretion  may  be  500  c.c.  or  more.  Children  fed 
artificially  excrete  larger  quantities  of  urine  than  do  breast 
fed.  It  is  almost  impossible  to  estimate  the  frequency  of 
urination  in  the  young  infant.  As  a  rule,  there  is  not  a 
greater  interval  than  two  hours  between  urinations  while 
awake,  and  not  longer  than  four  hours  during  sleep.  CoHc 
and  nourishment  disturbances  are  very  apt  to  increase  the 
frequency  of  urination.  According  to  Moll^  the  urine  of 
the  normal  breast-fed  infant  does  not  contain  phosphorus 
in  sufficient  quantities  for  it  to  be  detected  by  our  present 
chemical  technic. 

In  the  normal  breast-fed  baby  defecation  occurs  twice  a 
day.  The  stool  is  orange-yellow  in  color,  of  a  sHght  pun- 
gent odor,  soft  and  mealy,  or  stringy  in  appearance.  The 
reaction  is  acid.  The  bacterial  flora  is  Gram  positive 
(BaciUus  bifidus  communis).  The  stool  of  the  normal  arti- 
ficially fed  infant  is  passed  but  once  a  day.  If  milk  be 
1  Jahrb.  f.  Kinderheilk.,  1909,  IxLx,  129,  450. 


PLATE  II 


•^^^^^*li^  /J^' 


Stool  of  normal  infant  (vd  on  breast  milk. 


ATTRIBUTES    OF   THE    NORMAL    CHILD  69 

the  only  constituent  of  the  food,  the  color  is  lemon-yellow, 
while  if  malt  or  starch  be  given,  the  color  may  be  either 
light  or  dark  brown.  The  odor  is  frecjuontly  offensive. 
Reaction  acid.  There  is  much  more  tendency  to  the 
*'  formed "  stool,  and  the  general  appearance  is  more 
homogeneous  than  is  the  breast  stool,  perhaps  "  salve- 
like "  will  best  describe  it.  Bacterial  flora  is  Gram  nega- 
tive. 

During  the  first  few  days  of  life  the  muscular  action  of 
the  child  is  consumed  in  nursing  and  in  irregular  movements 
of  the  extremities,  which  show  lack  of  intention  and  direc- 
tion. The  cry  is  never  accompanied  by  lacrimation,  which 
rarely  appears  before  the  third  month,  and  usually  not  un- 
til after  the  sixth.  According  to  Czerny  and  Keller  the 
normal  infant  at  the  end  of  the  third  month,  when  placed 
upon  its  stomach,  will  arch  the  neck  and  look  around;  at 
the  end  of  the  sixth  month,  will  be  able  to  sit  up  unaided ; 
at  the  end  of  the  ninth  month,  will  be  able  to  stand,  and  at 
one  year,  will  begin  to  walk.  In  the  experience  of  the  writer 
it  has  usually  been  from  one  to  three  months  later  before  the 
child  was  able  to  stand  or  walk.  Usually  about  a  month 
before  walking  is  attempted  some  other  means  of  locomotion 
(as  crawling)  is  resorted  to.  The  activities  of  the  child  are 
of  great  importance  in  estimating  the  clinical  condition, 
and  should  always  be  observed.  Most  physicians  of  large 
experience  do  this  unconsciously. 

The  state  of  the  nervous  system  is  best  shown  by  two 
symptoms,  the  sleep  and  the  cry.  A  normal  newborn 
baby  sleeps  practically  all  the  time,  perhaps  waking  only 
a  few  minutes  before  each  nursing  period.  During  infancy 
there  should  be  at  least  one  long  interval  of  iminterrupted 


70  INFANT    FEEDING 

sleep  of  perhaps  eight  hours'  duration  in  the  older,  and  six 
hours  in  the  younger,  infants.  Where  only  six  hours  is 
taken  at  one  time,  the  infant  should  have  at  least  three 
other  periods  of  three  to  four  hours  each.  At  the  end  of  the 
first  year  a  child  should  have  a  night  period  of  eleven  to 
twelve  hours  and  two  day  periods  of  two  to  three  hours 
each.  Throughout  infancy  the  sleep  should  be  verj'-  deep, 
so  that  even  the  slamming  of  a  door  in  the  same  room  will 
not  awaken  the  baby.  Often  the  depth  of  the  sleep  is  of 
great  clinical  value.  Any  disturbance  of  the  natural  sleep 
may  be  regarded  as  pathologic.  The  normal  infant  cries 
whenever  it  is  uncomfortable.  This  may  mean  that  it  is 
hungry,  or  it  may  mean  that  its  clothing  is  irritating  it, 
or  perhaps  it  may  wish  to  be  held.  The  cry  may  be 
very  harassing,  but  on  removal  of  the  cause  it  ceases. 
All  infants  cry  at  times,  and  perhaps  this  crying  aids  ex- 
pansion of  the  lungs. 

Another  characteristic  of  the  normal  infant  is  its  rela- 
tive immunity  to  infections  of  all  kinds.  Czemy  lays  much 
stress  on  this  point.  It  is  undoubtedly  true  that  disturb- 
ances of  nutrition  distinctly  lower  the  resistance  of  the 
infant,  and  in  all  probability  the  reverse  is  true  {i.  e., 
proper  food  increases  the  resistance).  A  good  instance  of 
slight  apparent  abnormality  of  the  child  predisposing  to 
infection  is  seen  in  exudative  diathesis.  It  should  be  stated 
here  that  Kleinschmidt^  was  unable  to  show  any  connection 
between  antibody  formation  and  the  kind  of  nourishment. 

Finkelstein  has  added  still  another  characteristic  of  the 
normal  infant  which,  perhaps  of  all,  is  the  least  easily  es- 
timated and  the  most  important;  that  is,  its  wide  tolerance 
1  Monatsschr.  f.  Kinderheilk.,  1913,  xii  (Orig.),  423. 


ATTRIBUTES    01'   THE    NORMAL    CHILD  71 

for  food.  In  the  porfcctly  normal  infant  the  amount  and 
composition  of  food  may  vary  within  wide  boundaries 
without  producing  nutritional  disturbance.  This  fact 
accounts  for  the  wide  difference  in  the  results  obtained  in 
feeding  by  any  one  method  or  with  any  single  kind  of  food. 
The  writer  has  occasionally  seen  babies  who  for  the  first 
few  months  of  life,  if  the  statement  of  the  mother  may  be 
accepted  as  true,  had  had  nothing  to  eat  but  a  thick  oat- 
meal gruel,  and  which,  on  examination,  showed  no  trace 
of  abnormality  and  no  nutritional  disturbance  except  per- 
haps a  slight  degree  of  rickets.  All  of  us  have  seen  young 
infants  apparently  perfectly  healthy  whose  sole  diet  has 
consisted  of  condensed  milk,  and  yet  we  know  that  perhaps 
•  the  most  severe  cases  of  nutritional  derangement  which  are 
encountered  are  in  young  infants  whose  food  has  consisted 
wholly  of  condensed  milk.  These  facts  can  only  be  ac- 
counted for  if  we  recognize  that  under  normal  conditions 
the  infant  manufactures  its  body  material  out  of  widely 
different  foods,  and  is  able  to  do  this  without  causing  any 
derangement  of  its  system. 


PART    II 

NOURISHMENT   OF   THE    INFANT   ON    THE 

BREAST 


CHAPTER  VII 
THE  HUMAN  BREAST   AND   BREAST-MILK 

ANATOMY  AND  PHYSIOLOGY  OF  THE  HUMAN  BREAST 

The  human  mammary  gland  is  a  compomid  racemose 
gland  consisting  of  several  lobes  and  lobules,  each  of  which 
is  drained  by  a  duct.  Several  of  these  ducts  join  just  be- 
fore reaching  the  nipple,  and  just  beyond  this  point  a 
spindle-shaped  enlargement  occurs,  beyond  which  the 
duct  continues  in  its  usual  size  to  open  in  the  nipple. 
Each  nipple  contains  fifteen  to  twenty  such  ducts. 

On  microscopic  examination  the  acini  are  found  to  be 
lined  with  cylindric  epithelium,  which  rests  on  a  rather 
dense  membrana  propria,  consisting  of  spindle  cells. 
The  adventitial  layer  which  lies  beneath  the  membrana 
propria  consists  of  a  loose  network  of  connective  tissue 
in  which  are  to  be  seen  leukocytes,  plasma-cells,  and  blood- 
and  lymph-vessels.  Around  the  separate  divisions  of  the 
gland  is  a  dense  cell-poor  interstitial  tissue,  while  between 
the  lobules  and  individual  acini  fat-cells  are  found.  Dur- 
ing the  period  of  lactation  these  is  frequently  an  increase 

72 


THE    HUMAN    BREAST    AND    BREAST-MILK  73 

in  the  number  of  acini  and  the  l)lood-vcssel  supply  is 
richer.  Often  there  is  seen  to  be  a  denudation  of  the 
menibrana  propria  for  some  distance  in  the  acini,  and  just 
before  the  formation  of  milk  the  epithelial  cells  appear  large 
and  swollen;  soon  after,  ruptured  or  squeezed  out  (Foster).' 
The  blood-supply  of  the  mammary  gland  is  derived  from 
the  thoracic  branch  of  the  axillary  and  in  part  from  the 
intercostals.  Surrounding  the  gland  is  a  plexus  of  veins. 
The  nerve-supply  is  derived  from  the  second  and  third 
dorsal  nerves. 

COLOSTRUM 

The  first  secretion  appearing  in  the  breast  after  the 
birth  of  a  child  is  known  as  colostrum.  It  is  a  thick 
lemon-yellow  fluid  which  coagulates  on  boiling.  Chemic- 
ally the  colostrum  consists  of  7.5  to  10  per  cent,  protein, 
2  to  2.5  per  cent,  fat,  2.5  to  3.5  per  cent,  sugar,  and  .3  to 
.4  per  cent,  salts.  The  proportion  of  lactalbumin  and 
casein  is  about  the  same  as  that  of  the  milk  proper,  so  that 
the  increase  in  protein  is  due  to  the  increase  in  globulin, 
which,  in  turn,  accounts  for  its  coagulation  with  heat. 
Birk^  calls  attention  to  the  ash-content.  He  finds  that  in 
100  grams  of  colostrum  the  total  ash  is  .2814.  The  various 
constituents  are  as  follows: 

Calcium 0360  grams. 

Magnesium 0093      " 

Potassium 0770      " 

Sodium 0544      " 

Phosphorus 1137      " 

The  phosphorus  content  is,  therefore,  more  than  double  that 
of  the  later  milk.    Langstein,  Rott,  and  Edelstein,^  examin- 

1  Text-book  of  Physiology,  1896,  p.  610. 

2  Monatsschr.  f.  Kinderheilk.,  1910,  ix  (Grig.),  595. 
« Zeitschr.  f.  Kinderheilk.,  1913,  vii,  210. 


74  INFANT   FEEDING 

ing  the  caloric  value  of  colostrum,  found  that  it  varied  be- 
tween 500  and  1500  per  liter,  and  that  the  highest  values 
corresponded  to  a  thick,  yellow,  tenacious  fluid.  Micro- 
scopically, besides  the  fat-globules  and  occasional  epi- 
thelial cell  and  some  leukocytes,  we  find  the  character- 
istic colostrum  corpuscles.  These  are  cells,  some  small, 
many  large,  which  contain  single  or  many  fat-globules. 
These  globules  are  surrounded  by  the  cell  protoplasm, 
and  occasionally  a  distinct  cell  nucleus  can  be  seen  crowded 
to  the  edge  of  the  cell.  The  source  of  these  corpuscles  is 
a  subject  of  some  dispute.  It  had  formerly  been  supposed 
that  they  were  epithelial  cells  in  which  were  included  fat- 
globules,  but  Czerny  is  of  the  opinion  that  they  are 
leukocytes,  because  of  the  fact  that  leukocytes  are  found 
in  the  colostrum  in  appreciable  quantities,  while  they  do 
not  appear  in  the  milk  itself,  Thomas^  states  that  both  the 
polynuclear  and  mononuclear  colostrum  corpuscles  possess 
a  distinct  phagocytic  action. 

Colostrum  is  present  throughout  the  latter  months  of 
pregnancy,  but  an  attempt  to  express  it  from  the  breast 
produces  severe  pain.  Usually  the  flow  of  colostrum  be- 
gins on  the  second  day  after  delivery,  the  corpuscles  ap- 
pearing on  the  fourth  or  fifth  day.  The  corpuscles  usually 
disappear  in  the  first  few  days,  but  may  continue  for  many 
weeks.  It  is  interesting  to  note  that  when  the  breast- 
milk  is  giving  out  these  corpuscles  reappear,  and  the  fluid 
begins  to  take  on  more  the  character  of  colostrum.  Colos- 
trum is  slightly  laxative  in  its  action.     According  to  Birk,^ 


1  Zeitschr.  f.  Kinderheilk.,  1913,  viii,  291. 

2  Monatsschr.  f.  Kinderheilk.,  1910,  ix  (Orig.),  595. 


THE    HUMAN    BREAST   AND    BREAST-MILK  75 

colostrum  is  a  necessary  food  for  the  newborn  infant  and 
cannot  be  replaced  by  ordinary  breast-milk  without  danger. 

BREAST-MILK 

The  change  from  colostrum  to  the  permanent  secretion 
of  the  mammary  gland  is  more  or  less  gradual,  consuming 
perhaps  a  week.  The  milk  proper  has  a  somewhat,  bluish 
tint,  and  appears  thinner,  as  a  rule,  than  cows'  milk.  Spe- 
cific gravity  is  about  1.028  to  1.035,  van-ing  with  the  con- 
centration and  the  fat-content.  The  reaction  is  slightly 
alkaline  or,  according  to  Da\idsohn,^  neutral.  Under  nor- 
mal conditions,  microscopically,  little  is  to  be  seen  but  fat- 
globules,  perhaps  an  occasional  epithelial  cell.  Under  patho- 
logic conditions,  bacteria  of  various  sorts,  pus-cells,  and  even 
blood  are  frequent  constituents.  The  WTiter  has  seen  one 
case  where  the  fat  layer  after  centrifugalization  was  a  deep 
orange  color.  In  this  case  it  was  necessary  to  take  the 
infant  from  the  breast  temporarily  because  of  a  severe  gas- 
tro-intestinal  disturbance.  Some  weeks  after,  however,  th^ 
child  resumed  the  breast-milk  wath  very  gratifying  results. 
Neither  microscopically  nor  by  culture  was  any  adequate 
explanation  of  this  fat  coloration  given. 

Chemical  Composition  of  Milk. — Chemically  the  human 
breast-milk  consists  of  proteins,  fats,  sugar,  salts,  and 
ferments.'  Even  under  perfectly  normal  circumstances 
and  in  the  same  woman  at  different  times  the  composition 
of  the  milk  may  vary  within  wide  boundaries.  There  is 
no  general  tendency,  so  far  as  has  been  determined,  for 

^Zeitschr.  f.  Kinderheilk.,  1913,  ix,  11. 

2  A  detailed  tabulation  of  the  various  results  of  examinations  of  the 
chemical  composition  of  breast-milk  will  be  found  in  Czemy  and  Keller, 
Bd.  i,  414-^31. 


76  IXFAXT   FEEDING 

any  one  constituent  of  the  breast-milk  either  to  increase 
or  decrease  as  the  period  of  lactation  advances.  It  is 
ven'  likely  that  all  chemical  variations  in  the  breast-milk 
not  due  to  local  or  general  diseases  are  well  "^-ithin  the  limits 
of  the  normal,  and  that  disturbances  in  children  nourished 
at  the  breast  are  due  to  a  defect  in  the  child's  organism  or 
to  inability  on  the  part  of  the  infant  to  thrive  on  the  quan- 
tity of  milk  which  it  obtains  (too  much  or  too  little).  A 
possible  exception  to  this  may  be  rickets  in  breast-fed  chil- 
dren, where,  according  to  Ramacci/  there  is  a  reduced 
calcium-content  in  the  milk. 

The  protein-content  of  human  breast-milk  varies  between 
1  and  2  per  cent.  Lactalbumin  and  casein  foiTn  the  chief 
constituents,  though  lactoglobulin  is  foimd  in  small  quan- 
tities. The  proportion  of  lactalbumin  to  casein  is  about 
1  to  2  or  3  to  -i.  Lempp  and  Langstein^  could  determine 
no  difference  in  digestibility  of  the  casein  and  the  lact- 
albumin of  breast-milk,  nor  could  Bergell  and  Langstein' 
determine  any  constant  chemical  variations  between  the 
casein  of  women's  milk  and  that  of  the  milk  of  lower  ani- 
mals, except  that  the  potassium  is  higher  (Langstein)  .^ 
In  this  connection  it  is  interesting  to  note  that  Finizio^ 
finds  that  about  15  to  25  per  cent,  of  the  total  nitrogen  in 
human  breast-milk  is  derived  from  non-protein  material, 
such  as  luea,  creatinin.  etc. 

The  fat  of  the  breast-milk  is  in  much  finer  emulsion  than 
that  of  cows'  milk,  and  varies  between  3  and  4.5  per  cent. 

1  La  Pediatria.  1910,  xviii.  665. 

2  Jahrb.  f .  Kinderheilk.,  1910,  kx,  363. 

3  Ibid.,  190S,  Lxviii,  .568. 

^  Ibid.,  1910,  Lxxii,  Ergansungsheft  1. 
6  La  Pediatria,  1908,  xvi,  401. 


THE    HUMAN    BREAST   AND    BREAST-MILK  77 

It  consists  principally  of  palmitin,  stearin,  and  oiein,  with 
traces  of  the  lower  fatty  acids,  such  as  butyric.  From  a 
general  standpoint  most  interesting  are  the  findin^^s  of 
Engel.^  In  examining  the  fat-content  of  the  milk  he 
determined  that  at  the  beginning  of  the  nursing  period  the 
proportion  of  fat  was  low,  and  that  as  the  period  advanced 
the  fat  increased  veiy  greatly.  In  most  cases  the  increase 
in  fat  was  steady  from  the  beginning  to  the  end  of  nursing, 
but  in  some  the  steady  upward  trend  of  the  fat-curve  was 
broken  in  the  middle  by  a  slight  depression.  We  see, 
therefore,  that  the  last  milk  from  the  human  breast  is 
high  in  fat,  an  analogous  condition  to  that  found  in  the 
cow. 

The  only  carbohydrate  found  in  breast-milk  is  milk-sugar. 
This  is  present  in  about  6  to  7  per  cent.  It  varies  less 
perhaps  than  does  any  other  of  the  organic  constituents. 

Cornelia  de  Lange,'^  by  examination  of  a  mixed  women's 
milk  from  33  women  in  the  fourth  to  tenth  day  after  deliv- 
ery, found  in  100  gm.  of  ash  the  following: 

KjO 19.9  per  cent. 

Na.O 29.6 

CaO 12.9 

Mg.0 2.9 

FcjOs 0.25 

P=05 17.9 

Ch 21.3 

The  figures  of  Schloss'  vary  somewhat  from  those  just 
quoted.     He  finds  that  the  calcium  in  early  milk  forms  about 


lArchiv.  f.  Kinderheilk.,  1906,  xliii,  181. 

«  Czerny-Kcller,  Bd.  i,  427. 

»  Monatsschr.  f.  Kinderheilk.,  1912,  x  (Orig.),  499. 


78  INFANT   FEEDING 

11  per  cent,  of  the  total  ash,  while  later  it  rises  to  about  20 
per  cent.    The  others  he  gives  as  follows: 

Sodium 10  per  cent. 

Potassium 30        " 

Chlorin 16  to  17  per  cent. 

Phosphorus about  20  per  cent. 

According  to  Orgler^  the  calcium  decreases  with  the  ad- 
vance of  the  lactation  period. 

In  mothers'  milk  the  iron  is  very  small  in  amount.  To 
supply  the  body  needs  during  the  first  months  in  all  prob- 
ability iron  is  stored  up  during  fetal  life,  since  it  is  not 
present  in  sufficient  quantity  in  the  food  to  supply  the 
demand. 

In  examining  the  calcium-content  of  mothers'  milk, 
Ramacci^  found  that  normally  it  varied  between  .09  to 
.12  per  cent.,  and  that  neither  the  age  of  the  mother  nor 
the  month  of  lactation  influenced  it.  He  founds  how- 
ever, that  the  mothers  of  rachitic  or  spasmophihc  infants 
produced  a  milk  which  was  low  in  calcium.  Bahrdt  and 
Edelstein^  came  to  much  the  same  result,  except  that  they 
found  the  calcium-oxid-content  to  be  only  .03  to  .04  per 
cent. 

Various  investigators  have  found  enzymes  in  the  milk, 
among  which  may  be  mentioned  a  proteolytic  ferment, 
galactase,  lipase  (Davidsohn^),  and  a  ferment  which  splits 
salol  into  phenol  and  salicylic  acid  (Usener^). 

So  far  as  we  know,  these  are  of  constant  occurrence. 
As  to  whether  they  are  vital  to  the  proper  action  of  the  milk 

1  Ergeb.  d.  inn.  Med.  u.  Kinderheilk.,  1912,  viii,  142. 

2  La  Pediatria,  1910,  xviii,  665. 

*  Jahrb.  f.  Kinderheilk.,  1910,  Ixxii,  Erganzungsheft,  16. 
«  Zeitschr.  f.  Kinderheilk.,  1913,  viii,  14. 
•*  Ibid.,  1912,  V,  431. 


THE   HUMAN    BREAST   AND    BREAST-MILK  79 

has  not  been  determined,  but  it  is  probable  that  their  pres- 
ence is  more  or  less  an  accident  rather  than  a  distinct  char- 
acteristic. 

Excretion  of  Drugs  in  Breast-milk. — Much  has  been  said 
about  the  passage  of  druys  through  the  milk,  but  little 
positive  evidence  of  such  is  at  hand.  Reed^  carefully 
collected  the  hterature  on  this  subject.  In  general,  one 
may  say  that  in  physiologic  doses  very  few  drugs  pass  over 
into  the  breast-milk,  while  in  poisonous  doses  most  of  them 
do.  Alcohol  has  probably  received  the  most  attention. 
It  has  been  found  that  in  doses  of  100  c.c.  no  alcohol  was 
detected  in  the  milk,  while  when  200  c.c.  were  given,  35  c.c. 
were  recovered  in  the  milk.  Alcohol,  therefore,  agrees 
with  the  general  rule.  No  chemical  proof  exists  of  opium 
or  its  derivatives  in  the  breast-milk  after  the  same  is  taken 
by  the  mother.  Atropin  or  belladonna  in  physiologic 
doses  do  not  appear  in  the  milk.  There  is  some  uncertainty 
about  chloral  hydrate,  chloroform,  and  ether,  but  enough 
indefinite  evidence  is  at  hand  to  make  us  cautious  in  their 
use.  Quinin  and  salicylic  acid  probably  do  not  pass  over. 
Potassium  and  sodium  hromid  do  appear  in  the  milk,  as  is 
shown  chemically,  as  do  also  antipyrin  and  phenacetin. 
Mercury  has  never  been  found  in  the  breast-milk,  in  spit€ 
of  the  often  repeated  assertion  of  the  favorable  action  of 
antisyphilitic  treatment  of  the  mother  on  the  nursing  child. 
On  the  other  hand,  iodin  and  its  derivatives  are  readily 
recognized.  Arsenic  has  been  found  in  the  milk  after  the 
use  of  Fowler's  solution  and  salvarsan  (CaflFarena^).  There 
is  doubt  as  to  iron  appearing  in  the  milk  because  of  the  pres- 

1  Surg.,  Gyn.,  and  Obst.,  190S,  \-i,  514. 
»  La  Pediatria,  1912,  .\x,  295. 


80  INFANT   FEEDING 

ence  of  that  metal  in  small  quantities  normally.  Bismuth 
and  copper  occur  in  insignificant  quantities.  It  is  likely  that 
thyroid  extract  does  occur  in  the  milk  after  its  administration 
to  the  mother,  at  least  the  clinical  reports  would  seem  to 
favor  this  view.  Much  difference  of  opinion  exists  as  to 
cathartics,  but  it  is  probable  that  most  of  them  are  conveyed 
through  the  milk  to  the  infant  in  quantities  sufficiently  large 
to  cause  a  slight  laxative  action,  at  times  perhaps  more. 

As  regards  bacteria,  the  Staphylococcus  alhus  can  be 
grown  from  practically  every  specimen  of  breast-milk, 
even  if  all  antiseptic  precautions  are  used  in  pumping  or 
otherwise  emptying  the  breast,  so  that  its  presence  cannot 
be  regarded  as  pathologic.  The  source  of  this  organism  is 
probably  the  skin.  Staphylococci  in  large  numbers,  espe- 
cially if  pus  be  present,  can,  however,  be  regarded  as  point- 
ing strongly  to  either  a  local  or  general  infection.  It  has 
been  shown  clinically  that  the  organism  causing  pneumonia 
(the  pneumococcus)  and  those  of  the  other  acute  infectious 
diseases  can  pass  into  the  milk.  This  is  also  true  of  tuber- 
culosis. It  is  interesting  to  note  that  the  milk  of  lactating 
women  suffering  with  typhoid  fever  often  gives  the  Widal 
reaction.  At  times  diphtheria  toxin  and  antitoxin  have 
been  found  in  the  breast-milk.  Kleinschmidt^  has  demon- 
strated the  presence  of  bactericidal  amboceptors  in  breast- 
milk,  which  he  regards  of  much  importance  since  the  infant's 
blood  contains  a  sufficient  complement.  JundelP  has  found 
that  the  opsonic  index  is  about  the  same  in  human  and 
breast-milk,  it  being  between  2  and  3.  Boiling  the  milk 
seems  to  make  no  difference. 

1  Monatsschr.  f.  Kinderheilk.,  1911,  x,  254. 

2  Nord.  Med.  Ark.,  1912,  Afd.  II,  (Lit.),  44. 


THE   HUMAN    BREAST   AND    BREAST-MILK  81 

FACTORS  INFLUENCENG  THE  MILK 

Why  within  a  few  hours  or  days  after  birth  of  a  child 
the  breast-milk  should  begin  to  flow  has  been  the  subject 
of  much  controversy.  The  work  of  Basch^  throws  some 
light  upon  this  matter.  By  injecting  a  placental  extract 
subcutaneously  into  a  bitch  which  had  previously  littered, 
but  which  at  the  time  was  producing  no  milk,  he  was  able 
to  cause  a  distinct  action  of  the  mammary  gland,  and  this 
even  after  the  gland  had  been  removed  from  all  nerve  con- 
nections and  been  transplanted  beneath  the  skin  of  the 
back.  He  was  unable  to  produce  the  same  results  in  a 
bitch  which  had  not  previously  Uttered  until  after  the 
transplantation  of  the  ovary  of  a  bitch  which  contained 
corpora  lutea.  He  was  able  to  produce  milk  secretion  in 
the  glands  of  3  four  months'  old  infants  by  repeated  injec- 
tions of  placental  extract.  This  work  would  certainly  sug- 
gest a  distinct  connection  between  the  placental  products 
and  the  beginning  of  milk  secretion. 

In  regarding  the  factors  which  influence  the  breast-milk, 
one  must  always  bear  in  mind  that  it  is  a  true  secretion, 
and  in  an  insignificant  measure  only,  an  excretion. 

Since  this  is  true,  the  food  ingested  by  the  mother  can 
only  indirectly  influence  the  amount  and  composition  of 
this  milk.  Therefore,  we  can  expect  no  regular  result  from 
the  same  alterations  of  diet  in  any  series  of  cases.  The 
increase  in  the  fat  of  the  mother's  food  will  by  no  means 
regularly  increase  the  fat  of  the  milk;  the  same  holds  true 
of  the  proteins.  In  fact,  we  must  come  to  the  rational  con- 
clusion that  changes  of  diet  in  the  mother  are  of  value  only 

'  Monatsschr.  f.  Kinderheilk.,  1909,  viii,  513. 


82  INFANT   FEEDING 

in  SO  much  as  they  affect  her  general  bodily  health,  and, 
agaiQ,  and  of  no  less  importance,  in  so  much  as  they  influ- 
ence her  psychic  condition.  Too  much  stress,  however, 
cannot  be  laid  on  the  relation  of  the  psychic  condition  of 
the  mother  to  the  flow  of  the  breast-milk.  It  is  frequently 
necessary  to  make  an  anxious  mother  feel  that  she  is  diet- 
ing for  the  sake  of  the  infant,  and  the  psychic  result  of 
such  sacrifice  is  frequently  of  great  value.  In  no  other 
way  can  we  explain  the  most  contradictory  results  of  die- 
tetic treatment  in  cases  of  reduced  breast-milk  which  are 
reported  in  the  Hterature  and  which  we  all  have  met  in 
practice. 

Healthy  women  are  certainly  better  able  to  nurse  their 
children  than  sick  ones.  By  healthy  women  the  writer 
does  not  refer  to  those  having  a  large  amount  of  adipose 
tissue  nor  to  those  addicted  to  excessive  exercise,  but 
to  the  women  who  exercise  the  functions  of  woman's 
existence  normally.  If  we  can  accept  this  as  a  premise,  it 
certainly  follows  that  our  efforts  in  the  case  of  every  nursing 
mother  should  be  directed  toward  keeping  up  her  general 
health  to  the  optimum. 

To  a  certain  extent,  but  only  to  a  certain  extent,  is  regu- 
lation of  the  diet  of  any  avail.  We  should  avoid  in  the  diet 
such  foods  as  are  not  conducive  to  the  general  health  of  the 
individual.  We  should  endeavor  to  regulate  the  bowels  of 
the  mother  by  attention  to  diet  rather  than  by  resort  to 
drugs.  We  should  study  the  psychic  side  of  the  mother, 
and  gauge  our  advice  as  to  diet  to  a  great  extent  by  her 
attitude.  To  preserve  general  health  a  certain  amount 
of  exercise  is  always  of  value.  Too  much  exercise  is  as 
little  to  be  desired  as  too  Httle.     The  amount  of  exercise 


THE    HUMAN    BREAST   AND    BREAST-MILK  83 

should  (,k'|jL'iid  to  a  large  extent  upon  what  tlie  patient  her- 
self has  been  accustomed  to. 

It  is  certainly  true  that  in  some  cases  the  nursing  babies 
of  menstruating  women  do  not  do  well.  Frequently  at  the 
time  of  the  menstruation  the  child  is  cross  and  sleep  is 
disturbed,  and  the  stool,  which  has  previously  been  normal, 
becomes  somewhat  more  frequent,  of  green  color,  and  curdy. 
This  condition  is,  however,  in  nearly  all  cases  temporary  and 
ceases  with  the  end  of  the  menstruating  period.  Under 
such  conditions  it  is  not  advisable  to  remove  the  child  from 
the  breast  even  temporarily.  Menstruation  of  the  mother 
in  itself  is  not  sufficient  cause  for  removal  of  the  child  from 
the  breast.  It  is  interesting  to  note  that  Bamberg/  how- 
ever, has  been  able  to  find  no  difference  either  in  quantity  or 
chemical  composition  during  the  menstrual  period. 

Among  the  laity  there  is  a  widespread  idea  that  preg- 
nancy in  a  nursing  woman  is  an  absolute  indication  for 
weaning  the  baby.  Poirier  (quoted  by  Budin)^  found  that 
72  per  cent,  of  lactating  pregnant  women  could  nurse  their 
babies.  We  so  frequently  see  women  who  have  passed 
through  the  early  months  of  pregnancy  giving  nourishment 
to  their  babies,  and  the  latter  thriving,  that  we  can  hardly 
regard  pregnancy  itself  as  a  direct  indication  for  weaning. 
Usually,  if  any  disturbance  of  nutrition  develops  in  the 
child,  it  is  only  after  the  mother  learns  her  condition.  This 
frequently  acts  as  a  distinct  nervous  shock,  and  here  again 
we  have  the  psychic  element  to  deal  with.  Among  certain 
classes  of  women,  where  the  pregnant  state  is  almost  con- 
tinuous after  marriage,  it  is  not  unusual  to  see  a  six, 

1  Zeitschr.  f.  Kinderheilk.,  1913,  vi,  424. 
*  The  Nursling,  London,  p.  96. 


84  INFANT   FEEDING 

seven,  or  even  eight  months'  pregnant  woman  nursing  a 
healthy  child. 

INDICATIONS  FOR  REMOVAL  OF   CHILD   FROM  BREAST 

The  importance  of  this  subject  cannot  be  overestimated. 
One  of  the  most  responsible  positions  in  which  a  physician 
can  be  placed  is  that  of  determining  if  there  is  sufficient 
cause  for  removal  of  the  child  from  the  breast.  Even  with 
the  utmost  care  and  honesty  the  future  may  show  us  to 
be  wrong  in  our  decision,  a  fact  which  may  mean  the  death 
of  the  infant.  One  cannot  emphasize  too  strongly  the  im- 
portance of  giving  the  infant  milk  from  its  mother's  breast 
whenever  it  is  possible  to  do  so.  All  indications,  with  one 
or  two  exceptions,  are  relative,  but  attention  should  be 
called  to  conditions  which  may  arise. 

If  by  weighing  a  child  before  and  after  each  nursing  it 
is  found  that  it  is  obtaining  little  or  nothing  from  the  breast, 
and  if  this  is  due  to  insufficient  supply  and  not  to  dyspepsia, 
the  infant  should  either  be  taken  from  the  breast  or  mixed 
feeding  should  be  resorted  to,  depending,  to  a  large  extent, 
upon  the  amount  of  breast- milk  obtained  by  the  child. 

During  the  fever  stage  of  the  acute  infectious  diseases  the 
child  must  be  removed  from  the  breast.  During  conva- 
lescence it  is  not  often  possible  for  the  mother  again  to 
nurse  the  infant,  both  because  of  her  depleted  condition 
and  because  of  the  failure  of  the  milk  to  appear.  Open 
tuberculosis  in  the  mother  is  an  absolute  contraindication 
to  breast  nursing,  both  because  of  the  almost  absolute 
certainty  of  the  infection  of  the  child,  and,  second,  because 
of  the  bad  effect  on  the  mother.     Latent  tuberculosis  (es- 


THE    HUMAN    BREAST    AND    BREAST-MILK  85 

pecially  of  the  peribronchial  lymi)h-fj!;lands)  is  so  frequently 
present  in  all  adults  as  to  be  disre^^arded  in  this  connection. 

The  path  to  follow  in  bone  and  gland  tuberculosis  must 
depend  upon  the  extent  and  severity  of  the  infection.  In 
very  mild  cases,  where  there  is  involvement  of  no  other  or- 
gans and  where  lactation  does  not  influence  unfavorably 
the  course  of  the  disease,  there  is  no  reason  for  removal  of 
the  child  from  the  breast. 

Whether  the  child,  mother,  or  both  have  manifest  signs 
of  syphilis,  the  baby  should  be  nursed  by  its  own  mother. 
One  should  remember  that  in  order  to  make  the  child 
thrive  it  is  just  as  important  in  this  instance  to  treat  the 
mother  as  to  treat  the  baby.  Under  no  circumstances 
allow  a  syphilitic  baby  or  the  offspring  of  syphilitic  parents, 
whether  that  child  shows  signs  of  syphilis  or  not,  to  suckle 
a  healthy  woman.    The  reason  for  this  is  obvious. 

Valvular  or  muscular  diseases  of  the  heart  are  not  of  them- 
selves contraindications  to  nursing.  For  instance,  a  slight, 
compensating  mitral  regurgitation  will  certainly  offer  no 
sufficient  reason  for  weaning.  In  severe  acute  affections, 
such  as  endocarditis  and  pericarditis,  the  case  should  be 
decided  according  to  the  same  rules  as  those  given  for  acute 
infectious  diseases. 

Nephritis  in  most  instances,  especially  in  the  acute  cases, 
is  a  contraindication  to  nursing,  but  certainly  a  woman  suf- 
fering with  chronic  nephritis  of  a  slight  degree  will,  if 
careful  of  her  diet,  be  well  able  to  nurse  her  baby. 

Insanity  is  a  direct  contraindication  to  nursing.  It  is 
conceivable  that  under  certain  circumstances  an  epileptic 
might  be  able  to  nurse  her  child,  but,  for  all  practical  pur- 


86  INFANT   FEEDING 

poses,  the  presence  of  epilepsy  of  the  mother  is  an  absolute 
contraindication  to  nursing. 

Violent  fits  of  anger  or  other  sudden  emotions  may  cause 
temporary  cessation  or  reduction  in  the  flow  of  milk,  and 
their  repeated  occurrence  should  be  guarded  against. 

Women  with  cancer  or  other  malignant  growths  are,  as  a 
rule,  unable  to  nurse  their  babies,  and,  even  though  able, 
probably  the  toxic  products  present  in  the  milk  render 
it  unfit. 

Other  general  affections,  except  under  unusual  conditions, 
do  not  affect  the  maternal  nursing. 

In  the  hreast  itself,  tuberculosis  of  one  or  both  breasts 
and  cancer  are  absolute  contraindications  to  nursing. 
Abscess  of  one  breast  rarely  necessitates  removal  of  the 
infant  from  the  other  except,  perhaps,  in  the  acute  febrile 
period.  Inverted  nipples  may  cause  great  difficulty,  which 
can  be  temporarily  overcome  by  the  use  of  a  breast-shield, 
but  it  is  practically  impossible  to  so  evert  the  nipple  that 
the  child  can  grasp  it,  and  sooner  or  later  the  attempt  to 
nourish  the  infant  with  the  help  of  the  nipple-shield  must 
prove  impossible,  because  of  the  failure  of  the  child  to  ob- 
tain the  requisite  amount  of  food  and  the  failure  of  the 
breast  to  properly  develop  its  lactating  powers.  Cracked 
and  painful  nipples  are  the  source  of  great  inconvenience, 
but  only  in  certain  instances  can  they  be  regarded  as 
indications  for  weaning.  If  a  cracked  nipple  does  not  heal 
under  applications  of  compound  tincture  of  benzoin,  then 
temporary  removal  of  the  child  from  that  breast  may  aid. 
The  great  danger  lies  in  infection;  therefore,  careful  anti- 
sepsis of  the  child's  mouth  and  the  breast  surface  should 
be  observed.     Painful  nipples  are  a  source  of  great  pain 


THE   HUMAN    BREAST   AND    BREAST-MILK  87 

and  annoyance,  and  the  effects  on  the  nervous  system  of  the 
mother  may  rarely  be  so  severe  as  to  make  removal  from 
the  breast  advisable. 

Hare-lip  and  deft-palate  in  the  nursing  infant  may  cause 
difficulty.  Hare-lip  is  not,  as  a  rule,  the  source  of  so  much 
trouble  in  the  early  months,  when  the  nursing  is  carried 
on  largely  by  the  hard  palate  and  gums,  and  later  the  case 
may  be  operated  upon,  which,  if  the  result  should  be  satis- 
factory, will  enable  the  child  to  fit  the  mouth  about  the 
base  of  the  nipple  in  such  a  way  as  to  enable  the  inspira- 
tory action  of  the  sucking  to  aid  in  emptying  the  breast. 

Cleft-palate  is  a  serious  difficulty.  It  is  necessary  to 
nurse  the  child  interruptedly,  so  that  it  can  get  its  breath. 
An  early  operation  is  advisable  if  the  state  of  health  of  the 
child  will  permit  it. 


CHAPTER  VIII 

TECHNIC    OF    BREAST    NURSING    OF   THE   NORMAL 

INFANT 

Care  of  the  Breast  and  Nipples. — Before  and  after  each 
nursing  the  nipples  and  the  adjoining  portion  of  the  breast 
should  be  cleaned  with  a  concentrated  solution  of  boric 
acid.  This  accomphshes  two  purposes:  it  helps  to  prevent 
infection  of  this  region  from  the  mouth  of  the  infant,  which 
is  especially  likely  to  occur  if  a  fissure  or  abrasion  of  the 
nipple  is  present,  and  it  removes  any  infectious  material 
from  the  skin  of  the  breast  which  otherwise  might  be  taken 
with  the  food.  Between  nursings  the  nipple  and  adjacent 
skin  should  be  covered  with  a  clean  cloth  or,  if  practical, 
with  a  piece  of  sterile  gauze.  No  corset  should  be  worn 
which  in  any  way  presses  upon  the  breast. 

Position  of  the  Child  While  Nursing. — When  the  mother 
is  in  bed  the  child  should  lie  to  the  side  from  which  it  will 
nurse,  the  breast  being  held  away  from  the  nose,  so  as  to 
allow  free  passage  of  air.  With  the  mother  in  a  sitting 
posture,  the  child's  head  should  rest  on  the  raised  knee, 
the  foot  being  supported  on  a  stool,  and  the  child  nurse 
from  the  pendulous  breast  of  the  same  side.  In  this  way 
the  breast  is  easily  held  from  the  baby's  nose  and  respira- 
tion is  free. 

Rotation  of  Breasts. — ^The  child  should  be  nursed  alter- 
nately, first  on  one  breast  and  then  on  the  other.     It  is 

88 


Fig.  4. — Proper  jjosilion  for  brciist    nurbin^;,  with  mother  in  rccuiiibent 

position. 


Fig.  5.-  I'ropcr   posilioii   for  l)r(';ist    mirsiii'i,   with   inollur  in  sitting 

l)o.sition. 


TECHNIC   OF   BREAST   NURSING   OF    NORMAL   INFANT     89 

possible  that  when  the  breasts  are  low,  as  in  the  convales- 
cence from  some  acute  illness,  it  may  be  better  to  allow  the 
child  to  nurse  both  breasts  at  the  same  nursing.  This, 
however,  frequently  disturbs  the  child,  and  rarely,  if  ever, 
increases  the  flow  of  milk. 

The  amount  of  food  which  the  normal  breast-fed  infant 
obtains,  of  course,  varies  with  the  age  and,  to  a  great  extent, 
with  the  individual.  Any  table  hke  the  following  can  only 
claim  to  give  a  general  idea  of  what  is  usually  to  be  expected. 
The  mere  fact  that  any  infant  gets  more  or  less  than  any 
such  table  may  show,  in  itself  does  not  mean  that  the  child 
is  getting  too  much  or  too  little  food ;  this  must  be  judged 
from  the  infant's  general  condition.  The  table  is  only  given 
as  a  general  guide,  and  should  be  regarded  as  such : 

Daily  Quantitt 

Time.  Cubic  centimeters.  Ounces. 

First  week 250-300  8-10 

First  month 600-650  19-20 

Second  month 815-820  26 

Third  month 800-850  25-27 

Fourth  month 850-900  27-29 

Fifth  month 900-950  29-30 

Sixth  month 1000  32 

From  this  table  it  will  readily  be  seen  that  after  the  first 
month  the  increase  in  the  amount  of  breast-milk  which 
the  average  child  obtains  is  minimum,  amounting  in  five 
months,  at  the  most,  to  6  ounces. 

The  amount  of  the  individual  feeding  varies  greatly, 
according  to  the  child  and  especially  according  to  the  inter- 
val between  nursings.  On  the  first  day  it  is  best  to  give 
only  sterile  water  sweetened  with  saccharin.  On  the 
second  day  the  child  should  obtain  only  1  ounce  or  a  frac- 


90  INFANT   FEEDING 

tion  of  an  ounce  at  each  feeding.  By  the  end  of  the  first 
week,  if  tlie  infant  is  nursed  at  four-hour  intervals,  it  should 
get  about  10  to  12  ounces  in  twenty-four  hours,  or  about  2 
ounces  to  a  nursing.  The  increase  from  now  on  is  gradual 
— at  the  end  of  the  first  month  being  3  to  3J  ounces  at  a 
single  period,  during  the  second  and  third  months  about 
5  ounces,  and  after  this  httle  gain,  being  about  6  ounces 
at  six  months. 

There  has  been  much  discussion  as  to  the  length  of  the 
interval  between  nursings.  Those  who  advise  a  short 
interval  (two  hours)  think  that  such  stimulates  the  breast 
secretion  by  repeated  withdrawal  of  the  milk,  and  that  the 
infant  by  nursing  so  often  gets  less  from  the  breast,  and 
hence  does  not  distend  the  stomach.  The  advocates  of 
the  long  interval  (four  hours)  assert  that  by  allowing  the 
breast  to  become  full  each  time  between  nursings  we  pro- 
mote a  better  action  of  the  breast,  and  hence  a  greater  sup- 
ply of  milk,  and  that  by  giving  the  food  to  the  infant  at 
long  intervals  you  give  its  stomach  a  rest,  and  that  part 
of  the  food  taken  passes  almost  immediately  through  the 
pylorus,  consequently  the  stomach  is  not  distended.  This 
is  perhaps  the  most  important  question  of  all  those  con- 
nected with  breast  feeding,  and  must  be  definitely  de- 
cided. It  seems  to  the  writer  that  the  latter  position  is 
more  rational,  and  in  his  hands  and  that  of  several  of  his 
obstetric  colleagues  has  met  with  unexpected  success.  It 
is  certainly  true  that  in  two  hours  the  infant's  stomach  is 
not  empty.  To  add  food  to  a  stomach  which  already  con- 
tains partially  digested  food  would  seem,  and  is,  injurious. 
This  is  doubly  so  when  we  stop  to  think  that  the  last  milk 
from  the  breast  is  rich  in  fat,  and  that  if  the  breast  be 


TECHNIC    OF    BREAST    NURSIXG    OF    NORMAL    IN'FANT     91 

emptied  at  frequent  intervals  it  has  not  time  to  fill  com- 
{)letely,  and  hence  gives  a  food  rich  in  fat,  that  organic 
food-stuff  which  remains  longest  in  the  stomach.  It  has 
been  the  custom  of  the  writer  for  the  past  few  years  never 
to  feed  any  infant  oftener  than  every  four  hours.  New- 
bom  infants  are  put  to  the  breast  every  four  hours  during 
the  day  and  night.  If  the  mother  can  be  pei*suadcd  to  carry 
out  these  orders,  there  is  no  better  prophylactic  for  over- 
feeding and  consequent  colic.  The  best  hours  for  nursing 
are  2,  6,  and  10  a.  m.  and  2,  6,  and  10  p.  m.  In  infants 
over  a  month  old  one  night  nursing  is  sufficient.  This 
should  be  given  at  midnight.  If  a  baby  has  been  fed  irreg- 
ularly at  short  intervals,  or  even  regularly  every  two  hours, 
it  will  require  emphasis  on  the  part  of  the  physician  to  have 
his  orders  obeyed,  but  I  am  sure  that  he  wiU  never  regret 
the  change  if  the  results  on  the  child  alone  are  taken  into 
consideration. 

Stress  should  be  laid  upon  regularity  in  nursing.  In 
the  first  place,  this  regularity  acts  most  beneficially  on  the 
infant's  nervous  system  and  accustoms  it  to  certain  times 
for  food,  rest,  and  play.  In  the  second  place,  it  aids  diges- 
tion. And  again,  regularity  makes  the  breast-milk  more 
uniform  in  quantity  and  quality.  One  is  frequently  asked 
to  state  the  length  of  time  that  the  child  should  remain  at 
tJie  breast  for  a  single  nursing  period.  In  my  experience  this 
is  absolutely  an  individual  question.  The  ease  with  which 
the  baby  obtains  its  food  varies  as  much  as  do  the  breasts 
of  different  women.  Again,  some  children  are  weak,  some 
strong,  some  without  appetite,  some  greedy.  As  an  arbi- 
trary limit  it  is  probably  not  well  to  leave  a  baby  at  the 
breast  longer  than  fifteen  or  twenty  minutes.     In  restrict- 


92  INFANT   FEEDING 

ing  the  time  at  the  breast  we  must  always  take  into  consid- 
eration that  in  the  first  five  minutes  the  child  gets  as  much 
as  in  the  next  ten. 

To  determine  the  amount  of  milk  which  is  obtained  from 
the  breast,  the  baby  can  be  weighed  before  and  after  nurs- 
ing. This  can  only  act  as  a  rough  guide,  since  different 
babies  require  different  amounts  of  food  in  order  to  thrive 
properly.  If  the  baby  be  weighed  under  the  same  condi- 
tions (naked)  at  the  same  hour  in  the  day,  and  at  the  same 
time  in  relation  to  the  taking  of  food,  if  breast  fed  it  may 
gain  6  ounces  a  week  and  be  normal,  provided  no  untoward 
symptoms  are  present.  A  greater  gain  may,  in  exceptional 
instances,  be  followed  by  no  injurious  consequences,  but 
not  many  babies  can  take  care  of  an  amount  of  food  req- 
uisite to  produce  greater  gain  in  weight  without,  in  a  short 
time,  paying  for  their  greediness. 

It  is  well  in  the  first  months  of  life  to  accustom  the  baby 
to  take  water  from  a  bottle.  Later,  occasionally  a  bottle 
feeding  should  be  substituted  for  a  nursing,  in  order 
to  accustom  the  infant  to  the  bottle  and  thus  make 
weaning  less  diflScult.  If  started  early,  this  is  usually 
easy. 

There  is  general  agreement  that  after  the  ninth  month  a 
baby  thrives  better  if  fed  artificially.  Almost  without 
exception  the  baby  fed  a  longer  time  on  the  breast  shows 
signs  of  rickets  or  a  more  grave  nutritional  disturbance. 
One  of  the  materials  in  which  the  breast-milk  is  deficient  is 
iron,  and  this  important  constituent  must  be  given  in  the 
artificial  foods.  One  must  use  reason  as  to  the  length  of 
the  lactation  period,  since  weaning  in  the  hot  months  or 
just  previous  to  these  is  apt  to  be  followed  by  serious  con- 


TECHNIC   OF    BREAST   NURSING    OF    NORMAL   INFANT     93 

sequences.  It  is  never  of  advantage  to  the  child  to  nurse 
it  longer  than  one  year. 

The  question  may  arise  as  to  whether  one  woman  can 
with  advantage  nurse  more  than  one  baby.  This  is  best 
answered  by  citing  the  cases  of  wet-nurses  in  large  found- 
ling homes;  here  we  find  one  woman  nursing  two,  three, 
and  even  four  babies;  in  fact,  Budin  mentions  one  nurse 
who  nourished  five  for  a  short  period.  Naturally,  every 
woman  cannot  be  expected  to  do  this,  but  the  reaction  of 
the  breast  to  the  increased  stimulation  is  often  surprising. 

It  is  frequently  of  advantage  to  put  the  infant  to  the 
breast  again  after  it  has  been  removed  for  a  shorter  or 
longer  period.  In  most  cases  we  can  expect  very  little 
success  if  the  child  has  been  away  from  the  breast  for  a 
longer  time  than  a  week.   That  it  is  never  too  late  to  try,  the 

following  case,  I  think,  will  illustrate:  Baby  S was  bom 

at  Provident  Hospital,  and  on  the  fifth  day  developed  a 
high  fever,  with  diarrhea  and  vomiting,  although  it  had 
been  fed  exclusively  on  the  breast.  On  removing  the  child 
from  the  breast  and  substituting  artificial  food,  the  tem- 
perature dropped  and  the  gastro-intestinal  symptoms  dis- 
appeared. The  child  remained  at  the  hospital  for  six 
weeks,  with  no  gastro-intestinal  symptoms,  but  practically 
stationary  weight.  At  the  end  of  this  time  I  was  very 
much  surprised  to  have  the  father  ask  me  if  I  thought  the 
baby  could  go  home  and  nurse  its  mother.  On  inquiry 
I  found  that  the  breasts  had  been  kept  active  during  this 
time  by  artificial  means.  The  child  was  taken  home, 
given  the  breast-milk,  and  soon  became  a  fat,  healthy  baby. 

Weaning. — Weaning  is  frequently  a  very  difficult  task, 
and   always   requires   the   absolute   co-operation   of   the 


94  INFANT   FEEDING 

mother.  In  younger  infants  one  can  usually  substitute  a 
bottle  for  a  breast  feeding,  gradually  increasing  the  number 
until  the  child  is  completely  weaned. 

In  infants  over  six  months  of  age,  however,  to  attempt 
such  a  procedure  is  usually  without  effect.  No  way  is 
open  except  sudden  removal  from  the  breast  and  feeding 
entirely  with  artificial  food.  It  is  often  remarkable  and 
rather  disturbing  the  stubbomess  with  which  these  children 
will  hold  out,  but  there  is  no  grave  danger,  and  their  will 
must  be  matched  by  those  of  the  attendants.  As  a  pro- 
phylactic measure  it  is  always  well  to  accustom  the  child 
to  the  bottle  early  in  life. 

Wet-nursing. — In  the  United  States  wet-nursing  rep- 
resents a  very  difficult  problem  for  the  physicians  to  solve. 
The  natural  independence  of  the  lower  classes  and  their 
failure  to  appreciate  superiority  of  any  sort,  combined  with 
the  frequent  haughtiness  of  their  employers  as  a  result  of 
newly  acquired  prosperity,  raises  almost  insuperable  bar- 
riers to  domestic  peace  when  a  wet-nurse  is  introduced  into 
the  home.  Most  of  the  problems  of  wet-nursing  are,  then, 
those  for  a  diplomatist,  in  which  capacity  the  physician 
must  exercise  his  powers.  In  choosing  a  wet-nurse  we 
must  frequently  depend  upon  her  friends'  statements  as 
to  her  moral  character.  We  must,  however,  take  every 
precaution  to  see  that  she  is  physically  healthy.  Three 
diseases  must  be  especially  guarded  against — tuberculosis, 
syphihs,  and  gonorrhea.  Physical  examination  will  usu- 
ally reveal  the  presence  of  tuberculosis,  but  such  is  not  true 
of  syphilis.  Where  possible,  a  Wassermann  reaction  should 
be  obtained.  As  to  gonorrhea,  a  careful  examination  of 
the  vaginal  secretion  should  be  made. 


TECHNIC   OF   BREAST    NURSING   OF   NORMAL   INFANT     95 

Perhaps  the  best  proof  of  the  ability  of  the  wet-nurse  to 
supply  food  is  to  be  found  in  the  health  of  her  infant.  This 
should  always  be  carefully  examined  and  all  signs  of  disease 
noted. 

In  instructing  the  wet-nurse  we  must  always  bear  in 
mind  that  her  anxiety  for  her  own  offspring  is  great,  and 
due  emphasis  must  be  given  it.  Aside  from  the  fact  that 
failure  to  properly  care  for  her  child  may  cause  serious  con- 
sequences because  of  the  effect  on  the  milk  of  the  woman's 
mental  state,  the  physician  is  morally  bound  to  see  that 
this  infant  receives  the  most  careful  attention.  Perhaps 
in  the  majority  of  instances  it  is  not  advisable  to  allow  the 
child  to  be  nursed  to  have  the  total  supply  of  milk  of  the 
wet-nurse.  As  a  rule,  this  would  be  to  favor  a  catastrophe 
from  overfeeding,  or  else  to  allow  the  breasts  of  the  wet- 
nurse  to  retrogress  because  the  weak  infant  was  not  strong 
enough  to  offer  them  the  proper  stimulation.  The  first  few 
days  should  never  be  the  criterion  of  the  usefulness  of  any 
given  wet-nurse.  The  complete  change  of  surroundings 
and  diet  are  frequently  the  cause  of  disturbances  in  the 
flow  of  milk,  and  until  the  woman  becomes  accustomed  to 
these  one  should  not  judge  of  her  fitness  as  a  nurse. 

Undoubtedly,  the  difficulties  surrounding  this  problem 
have  led  us  to  regard  it  as  a  means  of  last  resort.  From 
the  standpoint  of  practical  medicine  it  is  unfortunate  that 
this  is  true,  but  there  is  no  tendency  in  this  countr}^  for 
a  change  so  radical  as  to  cure  this  evil,  and  hence  it  is  likely 
that  wet-nursing  for  some  time  to  come  will  remain  in  its 
present  relative  relation,  and  that  our  most  extensive 
efforts  will  be  directed  toward  procuring  the  proper  arti- 
ficial food  for  the  nutritionally  disturbed  infant. 


96  INFANT   FEEDING 

Mixed  Feeding. — ^The  occasion  may  arise  to  nourish  an 
infant  partly  on  the  breast  and  partly  artificially.  The 
first  question  to  be  decided  is  as  to  its  advisability.  If 
the  woman's  milk  is  to  be  obtained  from  a  perfectly  healthy 
woman  who  has  an  abundant  secretion,  there  can  be  Httle 
doubt  in  most  cases  of  the  advantage  of  mixed  feeding 
over  wholly  artificial  feeding.  However,  when  this  is  tried 
at  a  time  when  the  mother's  milk  is  giving  out,  its  advis- 
ability must  be  gauged  by  the  amount  of  milk  secreted 
by  the  mother's  breast.  If  this  be  so  small  that  only 
sufficient  is  produced  to  make  up  two  nursings  in  twenty- 
four  hours,  it  is  frequently  necessary  to  remove  the  child 
from  the  breast  entirely  to  prevent  or  to  relieve  a  dyspep- 
sia. (See  Nutritional  Disturbances  in  Breast-fed  Infants.) 
In  using  mixed  feedings,  the  amount  and  composition  of 
the  artificial  food  should  depend  upon  the  age,  weight, 
etc.,  of  the  child;  in  general,  the  single  feeding  should 
correspond  to  that  used  in  the  normal  infant  under  Hke 
conditions. 

Under  proper  conditions  the  results  obtained  with  mixed 
feeding  are  very  desirable.  Even  a  small  quantity  of  good 
breast-milk  each  day  undoubtedly  raises  the  resistance  of 
the  child,  and  also  seems  to  aid  the  digestive  processes. 


CHAPTER  IX 

NUTRITIONAL  DISTURBANCES  IN  THE  BREAST-FED 

INFANT 

INTRODUCTION 

Nutritional  disturbances  are  of  very  frequent  occur- 
rence in  the  breast-fed  infant,  but  their  nature  is  usually 
so  mild  that  the  physician  is  not  consulted  until  they  have 
existed  for  some  time.  Happily,  in  most  instances,  these 
minor  disturbances  cure  themselves,  i.  e.,  disappear  with- 
out marked  change  in  the  method  of  nursing,  but  if  they 
do  continue,  they  infrequently  cause  irreparable  damage. 
A  chronic  nutritional  disturbance  in  a  breast-fed  infant 
may,  on  the  other  hand,  at  the  time  of  weaning  lead  to 
serious  consequences,  which  can  only  be  accounted  for  by 
the  history  of  a  foregoing  disorder. 

Though  starvation  from  too  little  food  can  scarcely  be 
regarded  as  a  nutritional  disturbance  per  se,  yet  it  should  be 
well  studied  in  order  to  know  its  symptoms  and  differ- 
entiate them  from  those  of  dyspepsia.  In  the  nutritional 
disturbances  of  breast-fed  as  well  as  in  those  of  artificially 
fed  infants,  Finkelstein's  classification  will  be  used:  (1) 
Weight  disturbance;  (2)  dyspepsia;  (3)  decomposition; 
(4)  intoxication.  For  practical  purposes  the  two  which 
are  encountered  sufficiently  often  to  be  discussed  sep- 
arately are  the  weight  disturbance  and  dyspepsia.  De- 
composition and  intoxication  are  so  uncommon  that  their 

7  97 


98  INFANT   FEEDING 

discussion  will  be  reserved  for  the  discussion  of  these 
conditions  in  the  artificially  fed  infant. 

UNDERNOURISHMENT 

This  can  happen  under  various  circumstances.  In  the 
early  weeks  of  lactation  the  breast-milk  may  give  out  with- 
out the  mother's  knowing  it,  and  she  may  be  surprised  to 
find  the  child  losing  in  weight.  Inverted  nipples  may  be 
the  cause  of  the  infant's  not  getting  enough  food,  but  this 
is  usually  anticipated,  and  the  lack  of  breast-milk  made  up 
with  artificial  food.  Hare-lip  or  cleft-palate  may  render 
it  impossible  for  the  infant  to  get  the  requisite  amount 
of  food. 

Rosenstern^  states  that  in  32  out  of  50  hospital  cases  the 
cause  of  underfeeding  was  lack  of  appetite  in  the  child. 
Unquestionably,  in  many  of  these  cases  there  is  a  distinct 
neuropathic  taint. 

Von  Reuss^  advises  to  distinguish  between  undernourish- 
ment and  exsiccation.  He  enumerates  the  causes  of  under- 
nourishment as  weak  suckling,  lack  of  appetite,  fear  of  the 
breast  on  the  part  of  the  child;  and  on  the  part  of  the  mother, 
cracked  nipples  and  deficient  milk-supply. 

The  condition  is  not  a  common  one.  It  occurs,  per- 
haps, more  frequently  in  the  first  few  weeks  of  life,  be- 
cause at  that  time  the  mother  is  least  able  to  nurse  her 
infant.  I  do  not  believe  that  this  ever  results  from  an 
abundant  milk-supply  being  "too  thin."  Galactorrhea 
may  rarely  be  the  cause. 

Symptoms. — The   first  thing  noticed  is  the  failure  of 

1  Deutsch.  Med.  Wochenschr.,  1912,  No.  39. 

2  Zeitschr.  f .  Kinderheilk.,  1912,  iv,  499. 


NUTRITIONAL   DISTURBANCES    IN    BREAST-FED    INFANT     99 

the  infant  to  gain  in  weight  or,  perhaps,  even  a  loss  in 
weight.  As  to  whether  the  weight  remains  stationary  or 
falls,  depends  altogether  upon  the  amount  of  food  ingested. 
If  this  be  about  half  the  normal,  then  the  weight  usually 
remains  stationary;  while  if  it  is  practically  nothing,  there 
is  a  loss  of  weight. 

The  amount  of  food  taken  can  be  determined  by  weighing 
before  and  after  nursing.  A  decrease  in  the  amount  taken 
from  the  breast  does  not  by  any  means  always  indicate  a 
deficient  milk-supply.  We  must  first  exclude  dyspepsia 
in  the  infant,  for  in  the  acute  stages  of  dyspepsia  the  infant 
takes  little  or  no  milk  from  the  breast.  The  breasts  them- 
selves are  usually  flabby,  and  the  child,  after  being  put 
to  the  breast,  soon  ceases  to  nurse,  and  often,  in  an  exhausted 
state,  falls  asleep.  These  infants  are,  as  a  rule,  not  rest- 
less, sleep  is  deep  and  unbroken  and  crying  is  not  a  notice- 
able symptom.  The  cry  is  not  sharp  and  piercing,  but  of 
a  whining,  piteous  character,  is  not  often  repeated  or  con- 
tinued for  a  long  time.  All  this  is  especially  true  in  the 
very  young  infant. 

There  is  no  vomiting  or  eructation  of  gas.  The  stools 
are  few  and  scanty,  often  only  stains  on  the  diaper.  They 
are  usually  brown,  but  may  be  greenish;  no  curds  are 
found,  but  some  mucus  may  be  present.  The  urine  is 
noticeably  scanty. 

The  temperature  is  usually  subnormal,  sometimes  mark- 
edly so,  except  in  the  early  days  of  life,  when  there  occurs 
what  is  known  as  inanition  fever.  In  the  writer's  experience 
this  has  been  very  common.  The  temperature  may  rise 
to  an  alarming  height,  registrations  of  105°  or  106°  F.  not 
being  unusual.     Careful  examination  fails  to  reveal  any 


100  INFANT   FEEDING 

focus  of  infection,  and  the  fever  disappears  in  a  few  hours 
after  the  infant  is  given  food.  Czemy  and  Keller^  regard 
this  as  due  to  bacterial  infection  from  the  intestines,  which 
is  overcome  by  the  change  of  the  intestinal  content.  This 
is  rendered  unfit  for  the  further  growth  of  the  bacteria  at 
fault,  by  the  ingestion  of  food.  Von  Reuss^  does  not  think 
that  the  nourishment  plays  any  part  in  the  production  of 
this  fever,  but  thinks  that  we  must  take  into  consideration 
destruction  of  tissue,  loss  of  water,  and  deficient  warmth 
regulation  in  the  newborn,  while  Heller^  regards  the  condi- 
tion as  due  to  abnormal  metabolic  processes  together  mth 
deficiency  in  warmth  regulating  functions. 

Undernourishment  rarely  reaches  a  severe  degree.  The 
skin  may  be  somewhat  flabby,  the  turgor  reduced.  Pallor 
is  not  a  characteristic  s;^Tnptom,  but  weakness  is  usual. 
The  heart-tones  in  the  early  stages  are  not  affected. 

Diagnosis. — ^The  most  distinguishing  feature  about  these 
cases  is  the  stationary  or  falling  weight,  with  no  symptoms 
of  gastro-intestinal  disturbance  or  discomfort.  If,  after 
repeated  tests,  the  weighing  before  and  after  nursing 
shows  but  a  small  amount  of  food  obtained,  the  evidence  for 
undernourishment  is  strong,  but  dyspepsia  must  always  be 
considered  (which  see).  A  failure  to  obtain  any  appreci- 
able amount  of  food  from  the  breast  rarely  if  ever  occurs  in 
dyspepsia,  and  should  be  regarded  as  strong  evidence  that 
the  failure  to  gain  weight  is  due  to  an  insufficient  amount 
of  food.  The  weight  test  will  usually  exclude  those  cases 
of  exudative  diathesis  where,  without  apparant  cause, 
in  the  first  few  weeks  of  life  the  children  fail  to  gain. 

1  Bd.  ii,  198. 

2  Zeitschx.  f .  Kinderheilk.,  1912,  iv,  32. 

3  Ibid.,  55. 


NUTRITIONAL   DISTURBANCES    IN   BREAST-FED   INFANT      101 

Inanition  temperature  often  offers  great  difficulties  in 
diagnosis  when  first  observed.  One  must  think  of  the  nu- 
merous infections  which  may  occur,  especially  those  most  in- 
timately connected  with  infection  at  the  time  of  labor,  such 
as  septicemia,  infected  umbilicus,  etc.  In  cases  of  inani- 
tion fever,  the  absence  of  symptoms  which  point  to  any 
general  or  local  disturbance  of  the  organism  is  most  sug- 
gestive. The  infant  does  not  appear  septic  or  even  very 
sick  unless  the  temperature  is  excessive.  Nothing  is  more 
striking  than  the  fall  of  the  temperature-curve  after 
the  ingestion  of  food.  In  a  few  hours  the  temperature 
drops  to  normal  and  remains  there,  unless  there  appears 
some  disturbance  of  an  entirely  different  nature. 

A  prolonged  starvation  may  very  closely  simulate  a 
severe  marasmus,  but  this  is  certainly  so  uncommon  in 
breast-fed  infants  that  it  need  be  only  mentioned. 

Prognosis. — ^This  condition,  if  recognized,  offers  an  ab- 
solutely good  prognosis,  unless  it  has  existed  for  so  long 
that  through  deficiency  of  food  the  organism  has  suffered 
material  damage.  This  degree  is  extremely  rare.  It  is, 
indeed,  very  questionable  whether  such  a  condition  can 
exist. 

Treatment. — ^The  condition  once  recognized,  the  treat- 
ment, of  course,  consists  in  supplying  food  to  the  hungry 
infant.  No  greater  precaution  need  be  taken  than  one 
would  exert  in  regulating  the  nourishment  of  a  normal  in- 
fant of  the  same  age  and  weight.  The  inanition  fever  falls 
so  quickly  after  the  ingestion  of  food  (or  at  times  even  of 
water)  that  other  treatment  of  this  symptom  is  unneces- 
sary. 


102  INFANT  FEEDING 

WEIGHT  DISTURBANCE 

This  condition  is  by  no  means  a  common  one.  The 
usual  disturbance  in  breast-fed  infants  is  dyspepsia,  and 
this  is  not,  as  a  rule,  preceded  by  any  determinable  period 
of  weight  disturbance.  Weight  disturbance  may,  then,  in 
the  breast-fed  infant  be  regarded  rather  as  a  short  prelimin- 
ary stage  to  dyspepsia,  and  as  such  will  be  discussed  under 
that  head.  The  weight  disturbance  when  present  is  prac- 
tically the  same  as  that  of  the  artificially  fed  infant  (which 
see  later),  except  that  the  tendency  to  severe  constipation 
is  usually  lacking. 

DYSPEPSIA 

Dyspepsia  is  by  far  the  most  common  and  most  important 
of  all  nourishment  disturbances  which  occur  in  the  breast- 
fed infant.  It  is  not  only  the  most  common,  but  the  most 
disagreeable,  and  in  a  large  number  of  cases  leads  to  re- 
moval of  the  child  from  the  breast  under  circumstances 
which,  with  a  little  care  and  patience,  could  be  easily 
remedied. 

Etiology. — In  studying  the  etiology  of  this  disturbance 
we  must  keep  in  mind  that  woman's  milk  is  that  food  for 
which  the  infant,  in  the  great  preponderance  of  cases,  has 
the  greatest  tolerance.  In  proportion  to  the  degree  of 
tolerance  for  the  given  food  must  be  the  dietetic  error  which 
causes  nutritional  disturbance  on  that  food.  Hence  in 
dyspepsia  in  the  breast-fed  child,  as  we  would  expect, 
the  error  is  usually  a  gross  one,  and,  therefore,  more  easily 
corrected. 

The  essential  cause  is  overfeeding,  whether  this  occurs 
by  giving  too  much  at  a  nursing  or  from  nursing  too  often. 
It  is  very  unusual  to  see  dyspepsia  in  a  breast-fed  infant  to 


NUTRITIONAL   DISTURBANCES    IN   BREAST-FED    INFANT      103 

which  the  breast  has  been  given  at  four-hour  intervals 
ever  since  birth.  This  may  be  due  to  the  fact  that  there 
is  not  an  oversupply  of  milk,  as  it  is  to  the  inability  of  this 
child  to  overfcod  on  such  regulation  of  food,  but  in  the 
opinion  of  the  writer,  from  close  observation,  the  latter 
condition  would  seem  to  be  the  important  one.  We  fre- 
quently see  infants  fed  as  often  as  every  two  hours,  and 
even  one  hour,  or  one  hour  and  a  half.  Many  of  these 
thrive  and  escape  nutritional  disturbance;  most,  however, 
at  some  period  show  dyspepsia  of  greater  or  less  degree. 

Nursing  at  irregular  intervals  is  a  frequent  source  of 
trouble,  mostly  because  the  irregularity  consists,  as  a  rule, 
in  nursing  the  child  when  it  cries.  This  cry  is  caused  very 
often  by  colic,  and  the  giving  of  food  is  the  one  thing  which 
should  not  be  done.  A  variety  -of  dyspepsia  usually  of 
slight  severity  is  found  in  children  on  mixed  feedings. 
This  seems  to  be  due  to  the  fact  that  the  breast-milk  when 
about  to  give  out  is  not  a  fit  food  for  the  infant.  Proof  of 
this  comes  when  the  removal  of  the  child  from  the  breast 
and  complete  substitution  of  artificial  food  is  followed  by 
a  cessation  of  dyspeptic  symptoms,  as  occurs  in  most  in- 
stances. 

As  to  whether  any  one  element  in  the  breast-milk  can 
be  regarded  as  the  causative  factor  in  this  condition,  it 
would  be  hard  to  say.  The  lactose,  which  is  so  potent  a 
factor  in  the  production  of  nutritional  disturbances  in  the 
artificially  fed  infant,  has  received  very  little  attention  in 
the  discussion  of  those  of  the  breast  fed,  and  very  little  is 
known  in  regard  to  its  action  under  these  circumstances. 
It  would  seem  a  very  diflBcult  task  to  estimate  the  value 
of  this  food-stuff  in  this  relation. 


104  INFANT   FEEDING 

It  is  easier  to  estimate  roughly  the  effect  of  the  fat.  As 
has  been  poiated  out,  the  last  of  the  milk  taken  from  the 
breast  during  a  nursing  period  is  rich  in  fat.  It  would  seem, 
then,  that  if  the  infant  were  fed  oftener  the  fat-content 
would  be  continuously  higher,  because  at  each  nursing 
the  gland  would  be  drained.  Again,  if  on  long  intervals 
the  child  showed  no  tendency  to  improve  and  the  fat  were 
regarded  as  a  cause,  a  limitation  of  the  time  at  the  breast 
would  reduce  the  amount  of  fat  in  the  food,  and  hence 
cause  an  ameHoration  of  the  symptoms,  which,  in  fact, 
does  occur.  On  the  other  hand,  although  in  both  these 
instances  the  fat  is  that  constituent  which  is  most  reduced, 
we  must  not  forget  that  at  the  same  time  the  total  amount 
of  food  is  reduced.  We  may  say,  then,  that  while  there  is 
Httle  evidence  that  the  other  constituents  of  the  breast- 
milk  are  the  cause  of  nutritional  disturbance,  the  position  of 
the  fat  in  that  role  is  not  conclusively  proved,  and  that  at 
present  we  must  content  ourselves  with  the  simple  state- 
ment that  overfeeding  of  all  constituents  of  the  milk  is  the 
cause  of  dyspepsia  in  the  breast-fed  infant,  with  suspicion 
pointing  strongly  to  the  fat  as  the  chief  source  of  disturb- 
ance. 

Symptoms. — Undoubtedly,  the  symptom  which  most 
often  is  the  reason  for  the  mother's  seeking  the  advice  of 
a  ph5^sician  is  "  coHc."  "Whatever  the  true  nature  of 
colic  may  be,  it  is  a  condition  associated  with  severe 
pain,  and  this  apparently  is  of  gastro-intestinal  origin. 
Usually  in  the  earher  stages,  which  correspond  to  the  lighter 
forms  of  colic,  a  sharp  cry,  repeated  almost  without  inter- 
ruption and  continued  over  a  longer  or  shorter  period  of 
time,  is  begun  with  a  more  or  less  definite  relation  in  point 
of  time  to  the  nursing  period. 


NUTRITIONAL   DISTURBANCES   IN    BREAST-FED   INFANT     105 

Sometimes  this  occurs  a  few  minutes,  sometimes  two  to 
three  hours,  after  nursing;  sometimes  lx)th.  When  the 
attack  comes  on  shortly  after  nursing  there  seems  to  be  a 
predominance  of  stomach  symptoms,  since  the  eructation 
of  gas  fre(|uently  brings  relief.  Where  the  attack  comes 
some  hours  after  nursing,  the  intestinal  tract  seems  to  be 
more  involved,  since  the  expulsion  of  flatus  sometimes 
brings  relief,  as  docs  colonic  flushing.  When  the  interval 
between  nursings  is  so  short  that  the  ingested  food  does 
not  have  time  to  reach  the  intestines  before  more  is  taken 
into  the  stomach,  the  attacks  may  mean  a  combination 
of  both  the  stomach  and  intestinal  irritation.  The  fore- 
going statements  refer  only  to  the  earlier  stages.  In  the 
later  stages  or  severe  cases  the  entire  gastro-intestinal 
tract  seems  to  be  affected,  and  hence  it  is  no  longer  pos- 
sible to  differentiate.  A  peculiar  form  of  colic  and  one 
which  is  frequently  seen  is  that  in  which  the  attack  comes 
at  a  certain  time  each  day,  usually  between  6  p.  m.  and 
midnight.  This  attack  usually  lasts  one  to  two  hours, 
and  perhaps  can  best  be  explained  by  the  accumulation 
of  irritant  products  in  the  gastro-intestinal  tract  following 
successive  feedings  at  short  intervals. 

During  the  attack  of  colic  the  thighs  are  held  flexed 
on  the  abdomen,  the  legs  on  the  thighs,  usually,  at  times, 
the  child  kicks.  The  abdomen  is  held  rigid,  the  arms  are 
often  thrust  out  frantically,  and  the  child  will  grab  at  what- 
ever is  within  reach  or  even  tear  its  face.  The  skin  of  the 
face  and  body  is  usually  suffused  with  blood  as  the  result 
of  the  exertion,  although  the  extremities  are  cold.  This 
latter  fact  has  doubtless  led  to  the  fallacious  idea,  held  by 
so  many  of  the  laity,  that  colic  is  the  result  of  chilling. 


106  INFANT   FEEDING 

Frequently,  previous  to  the  attack  the  child  is  restless, 
expels  more  or  less  gas,  and  perhaps  shows  the  so-called 
colic  "  grin."  After  the  attack  the  infant  is  not  so  ex- 
hausted as  would  be  expected;  it,  however,  usually  falls 
asleep.  The  sleep  is  light  and  subject  to  frequent  inter- 
ruptions, with  crying  and  restlessness. 

As  to  the  pathologic  condition  which  underlies  this 
symptom-complex,  little  is  known.  Colic  in  the  adult  is 
perhaps  best  known  as  lead-colic,  peritonitis,  and  post- 
operative "  gas  "-pains. 

In  all  these  conditions  is  a  marked  circulatory  disturb- 
ance of  the  intestinal  wall.  This  would  seem  to  be  the 
case  in  colic  in  infants.  The  coldness  of  the  hands  and  feet 
is  the  result  of  internal  congestion  rather  than  itself  a 
causative  factor. 

Though  the  most  prominent  and  annoying  of  all  the 
symptoms  of  dyspepsia  in  the  breast-fed  infant,  colic  is 
probably  not  so  indicative  of  severe  intestinal  disturb- 
ance as  are  those  symptoms  more  intimately  associated 
with  derangements  of  the  gastro-intestinal  tract.  Diar- 
rhea is  nearly  always  present.  The  stools  are  passed  usu- 
ally four  to  eight  times  in  twenty-four  hours.  The  feces 
are  grass-green  in  color  and  contain  mucus  and  curds  in 
varying  amounts.  Much  flatus  is  expelled,  often  preceded 
by  crying.  Occasionally  constipation  is  found.  In  these 
cases  the  stool  when  passed  is  usually  soft,  often  semifluid, 
so  that  the  disturbance  cannot  be  due  so  much  to  an  in- 
creased consistency  of  the  bowel-content  as  to  a  deficient 
peristaltic  action. 

Vomiting  is  very  frequent  in  these  cases  of  dyspepsia  in 
the  breast-fed  baby.     It  may  be  a  simple  spitting,  which 


NUTRITIONAL   DISTURBANCES   IN    BREAST-FED   INFANT      107 

may  or  may  not  gradually  be  transformed  into  a  true 
vomitus.  Vomiting  in  some  form  often  precedes  by  some 
weeks  the  other  active  symptoms  in  many  cases,  and  is  a 
valuable  symptom  as  a  warning  of  approaching  disturbance 
of  a  more  severe  degree.  During  the  attack  of  colic,  when 
eructation  of  gas  is  encountered,  there  is  often  forced  up 
with  the  gas  a  considerable  amount  of  food.  The  severity 
of  the  vomiting  more  than  that  of  any  other  symptom 
depends  upon  the  length  of  the  interval  between  nursings. 
If  this  has  been  very  short,  the  vomiting  is  most  frequently 
severe;  while  if  the  interval  has  been  long,  there  is  either 
no  vomiting  or  else  it  is  only  slight  or  occurs  only  at  the 
onset  of  the  trouble. 

Distention  is  not  a  common  symptom,  in  spite  of  the 
repeated  passage  of  flatus. 

The  temperature  shows  greater  variation  than  normally, 
and  tends  to  be  above  normal  rather  than  below.  The 
temperature  range  is  from  about  97.6°  to  100°  F.  Tem- 
peratures above  100°  F.  are  not  common,  and  lead  to  the 
suspicion  of  a  severe  gastro-intestinal  disturbance  or  a 
complication. 

The  skin  is  usually  fresh  and  pink  in  the  early  stages, 
but  if  the  condition  has  continued  for  some  time  the  child 
becomes  pale.  Tissue  turgor  is  perceptibly  reduced  only 
in  the  later  stages,  i.  e.,  if  the  dyspeptic  condition  has  con- 
tinued for  some  days  or  weeks. 

In  dyspepsia  the  heart-tones  are  not  modified  in  char- 
acter. The  pulse  is  somewhat  more  rapid  than  normal. 
The  character  and  rate  of  respiration  are  not  perceptibly 
changed. 


108  INFANT   FEEDING 

The  urine  very  often  has  a  strong  ammoniacal  odor, 
suggestive  of  a  slight  degree  of  acidosis. 

Nervous  disturbances  are  quite  frequent.  The  child  is 
cross  and  fretful  and  cries  frequently,  even  though  it  has 
no  colic.  The  sleep  is  light  and  disturbed,  often  lasting 
only  an  hour  or  two  at  a  time,  and  then  so  Hght  that  at  the 
shghtest  noise  the  infant  awakes  with  a  start.  Convul- 
sions are  rarely  met  with,  and  if  present  can  be  ascribed 
to  a  spasmophilic  diathesis,  and  are  usually  the  result  of 
some  nourishment  other  than  breast-mUk. 

Complications. — Perhaps  the  most  common  complica- 
tion of  this  condition  is  nasopharjmgitis,  from  infection  of 
the  lymphoid  material  in  that  region.  This  tends  to  pro- 
long the  gastro-intestinal  disturbance  by  increasing  very 
markedly  the  mucus  which  is  swallowed,  and  which,  in 
turn,  acts  as  a  gastro-intestinal  irritant.  The  result  of 
repeated  attacks  of  this  sort  is,  of  course,  the  formation 
of  adenoids,  mth,  at  times,  attacks  of  acute  otitis  media. 
The  primary  dyspepsia  probably  acts  only  by  lowering 
the  resistance.  Coughing  so  frequently  encountered  in 
such  cases  of  dyspepsia  can  probably  best  be  explained 
in  this  way. 

Continued  overfeeding  with  dyspepsia  in  children  with 
exudative  diathesis  results  often  in  the  appearance  of  a 
facial  eczema  or  a  seborrhea  of  the  scalp,  which  is  very 
resistant  to  treatment  and  exceedingly  annoying.  The 
appearance  of  such  conditions  as  pneumonia,  pyelocystitis, 
etc.,  during  the  course  of  a  dyspepsia  may  be  regarded  as 
accidental,  and  are  probably  only  in  small  measure  the 
result  of  this.  Dyspepsia  may,  however,  compHcate  any 
of  these  conditions  (which  see). 


NUTRITIONAL   DISTURBANCES    IN   BREAST-FED    INFANT      109 

Sequelae. — The  only  sequelae  of  any  note  are  those 
which  refer  to  the  gastro-intestinal  tract,  and  they  are  not 
common.  Intoxication  may  occasionally  occur,  but  it 
is  more  often  due  to  an  attempt  to  satisfy  the  child  with 
some  food  other  than  the  breast  (usually  sweetened  water 
or  condensed  milk),  and  hence  cannot  be  regarded  as  strictly 
a  result  of  the  breast  nourishment.  Decomposition  is  still 
less  common,  and  is  usually  due  not  to  the  gastro-intestinal 
disturbance,  but  to  some  intercurrent  affection  which  may 
have  been  overlooked. 

Diagnosis. — The  symptoms  which  are  most  suggestive 
of  this  condition  are  colic,  diarrhea,  vomiting,  and  slight 
temperature.  Very  important  is  the  weight-curve.  A 
marked  gain  in  weight  followed  by  a  stationary  period  or 
loss  is  most  conclusive  evidence,  since  none  of  the  con- 
ditions with  which  this  may  be  confused  is  likely  to  show 
this  pecuHar  curve. 

Dyspepsia  in  the  breast-fed  infant  must  primarily  be 
differentiated  from  underfeeding,  with  which  it  is  very 
frequently  confused,  leading  to  disastrous  results.  Colic 
is  not  present  in  underfeeding,  and  the  cry,  though  occa- 
sionally accompanied  by  eructation  of  gas,  and  though 
at  times  rather  persistent,  never  has  the  character  of  the 
cry  from  coHc. 

The  weight-curve  in  dyspepsia,  with  its  rapid  rise  and 
subsequent  fall,  is  not  to  be  found  in  underfeeding.  Usu- 
ally in  dyspepsia  the  amount  taken  at  a  nursing  is  excessive, 
though  in  the  acute  stages  it  may  be  greatly  reduced,  due 
to  nausea.  In  underfeeding  the  single  nursing  is  always 
reduced  in  amount.  The  presence  of  diarrhea  and  vomit- 
ing are  indicative  of  dyspepsia.    A  rise  in  temperature, 


110  INFANT   FEEDING 

though  slight,  is  in  favor  of  a  dyspepsia,  except  in  the 
first  few  days  of  fife.  Other  conditions,  such  as  nasopharyn- 
gitis, otitis  media,  pyelocystitis,  pneumonia,  etc.,  are  Hkely 
at  first  to  offer  difficulties  in  diagnosis,  but  almost  without 
exception  the  temperature  in  these  conditions  is  higher 
than  in  dyspepsia,  and  their  presence  is  revealed  on  careful 
examination  by  local  findings. 

Prognosis. — The  outlook  as  to  life  is,  almost  without 
exception,  good.  Dyspepsia  is  a  mild  disturbance  in  the 
breast-fed  infant  in  spite  of  some  very  annoying  symptoms, 
but  should  receive  prompt  attention,  not  because  of  the 
danger  while  the  child  is  on  the  breast,  but  because  of  the 
diflBculties  likely  to  be  encountered  when  the  infant  is 
weaned.  As  in  all  other  gastro-intestinal  disturbances  at 
this  time  of  life,  the  younger  the  child  the  worse  the  prog- 
nosis, but  in  the  breast-fed  infant  the  chances  of  a  de- 
composition following  a  dyspepsia  in  the  first  few  weeks 
of  life  is  very  slight,  especially  in  comparison  to  what 
occurs  so  frequently  in  the  infant  on  the  bottle.  The  dura- 
tion of  a  dyspepsia  depends,  first,  upon  the  length  of  the 
interval  between  the  first  onset  of  symptoms  and  the  in- 
stitution of  treatment,  and  upon  the  nature  of  the  treatment 
itself.  If  proper  treatment  is  instituted  upon  the  first 
appearance  of  disturbance  the  child  is  usually  well  on  the 
way  to  recovery  within  forty-eight  hours.  If,  however, 
the  symptoms  have  existed  for  some  days  or  weeks,  it  is 
almost  impossible  to  get  an  early  cessation  of  symptoms. 
Of  aU  the  symptoms,  colic  is  the  most  persistent  and  the 
one  which  resists  longest  to  treatment,  and  its  severity  and 
duration  is  in  direct  relation  to  the  duration  of  the  dyspep- 
sia itself.     Long  after  all   other  symptoms  have  disap- 


NUTRITIONAL  DISTURBANCES    IN   BREAST-FED    INFANT     111 

peared  colic  still  persists,  and  only  the  most  careful  regula- 
tion of  the  diet  will  bring  any  relief. 

Treatment. — Since  this  condition  is  due  to  too  much  food, 
the  first  indication  for  trcatm(>nt  lies  in  reduction  of  the 
food.  As  a  prophylactic  measure  the  observation  of  the 
four-hour  interval  between  nursings  from  the  very  begin- 
ning of  the  lactation  period  is  most  gratifying  in  its  results. 
While  this  does  not  insure  against  overfeeding,  it  at  least 
allows  the  food  to  leave  the  stomach  before  new  food  is 
put  into  it,  and  thus  removes  one  of  the  chief  causes  of 
discomfort. 

After  the  dyspepsia  has  made  its  appearance,  the  first 
indication  is  reduction  of  the  food  and  regularity  in  nursing. 
In  the  severer  cases  it  may  be  necessary  to  give  the  child 
only  barley-water  (sweetened  with  saccharin,  not  sugar) 
for  twenty-four  hours.  In  these  cases  it  is  never  well  to 
continue  this  starvation  diet  longer,  because  of  the  danger 
of  the  breast-milk  giving  out.  An  interval  of  four  hours 
during  the  day  should  be  observed  and  the  infant  should  be 
fed  once  at  night.  These  measures  are  by  no  means  always 
sufficient.  In  most  cases  it  is  not  only  necessary  to  lengthen 
the  interval  to  four  hours,  but  also  to  limit  the  time  at  the 
breast  to  five  or  even  three  minutes  each  nursing.  With 
so  little  stimulation  the  breasts  are  likely  to  cease  to  func- 
tionate well,  so  that  the  length  of  the  nursing  period  must 
be  increased  as  rapidly  as  possible.  It  is  usually  better  to 
keep  the  child  on  the  breast  at  all  hazards,  because,  with 
careful  attention  to  details,  the  ultimate  result  is  nearly 
always  satisfactory.  Except  in  the  treatment  of  colic  no 
drugs  are  necessary  in  the  treatment  of  dyspepsia;  calomel 
certainly  does  no  good  and  castor  oil  may  do  distinct 


112  INFANT   FEEDING 

harm.  Bismuth  and  astringents  are  rarely  if  ever  neces- 
sary, except  in  severe  cases  of  vomiting. 

Fresh  air  is  an  absolute  necessity  in  all  cases  of  dyspepsia. 
The  child,  even  in  the  dead  of  winter,  should  be  out-of-doors 
at  least  once  a  day.  It  should  sleep  in  a  room  which  has 
been  thoroughly  aired  and  has  the  window  open  all  the  time. 
Better  results  can  be  obtained  if  the  child  sleeps  in  the  open 
air  on  a  porch  or  balcony  during  the  time  of  its  daily  nap. 

Every  precaution  should  be  taken  against  chilling  in  cold 
weather,  and  one  should  be  at  least  as  careful  against  over- 
heating in  hot  weather. 

Careful  bathing  daily,  with  an  alcohol  rub  following,  is 
to  be  advised,  as  well  as  careful  attention  to  nostrils  and 
mouth.  Hygienic  measures  alone  are  of  great  importance 
in  the  treatment  of  these  cases,  and  should  be  definitely 
commanded  by  the  attending  physician. 

Symptomatic  Treatment. — Few  symptoms  need  special 
mention,  since  most  clear  up  on  the  general  treatment 
above  indicated. 

If  the  vomiting  is  persistent  and  severe,  stomach  wash- 
ing is  often  of  great  benefit.  This  is  very  easy  in  a  young 
infant.  The  apparatus  used  consists  of  a  small  glass  fun- 
nel and  a  male  catheter  (size  18  or  20  French).  If  a  glass 
funnel  cannot  readily  be  obtained,  the  barrel  of  a  large 
piston-syringe  is  admirably  suited.  All  apparatus  should 
be  thoroughly  cleaned  and  sterilized  before  using.  The 
infant  is  placed  on  its  back  on  the  table  and  the  arms 
secured;  the  abdomen  bared,  so  that  any  distention  of  the 
stomach  may  be  noted.  The  tube  is  then  moistened  with 
water,  introduced  into  the  pharynx,  and  gently  pushed 
downward.     When  the  stomach  is  reached  a  small  amount 


NUTRITIONAL   DISTURBANCES   IN   BREAST-FED    INFANT      113 

of  fluid  or  mucus  rises  into  the  funnel.  As  a  general  rule, 
plain  sterile  tepid  water  is  best  for  stomach  washing. 
The  amount  should  always  be  carefully  measured.  The 
water  is  then  slowly  introduced  into  the  funnel,  and  when 
signs  of  regurgitation  or  distention  appear,  is  siphoned  off, 
and  the  process  repeated  several  times. 

It  is  often  remarkable  how  much  good  one  such  stomach 
washing  will  do.  It  is,  however,  often  necessary  to  repeat  it, 
but,  as  a  rule,  not  oftener  than  once  a  day.  If  this  is  not 
successful,  bismuth  may  be  given.  This  is  best  given  in 
an  acacia  mixture  to  the  amount  of  2  to  3  grains  to  a  dose, 
repeated  every  four  hours,  or  given  fifteen  to  thirty  minutes 
before  or  after  feeding,  depending  on  whether  the  vomiting 
occurs  immediately  after  nursing  or  some  time  after. 

Diarrhea  is  slight  and  needs  no  special  attention.  Eruc- 
tations and  flatus  are  in  all  cases  closely  allied  with  cohc, 
and  as  such  will  be  discussed  under  that  head. 

Of  all  the  symptoms  of  dyspepsia  in  the  breast-fed  in- 
fant, colic  is  the  most  annoying  and  the  most  resistant  to 
treatment.  The  measures  directed  against  the  affection 
in  general,  such  as  reduction  of  food  or  starvation  diet 
and  hygienic  treatment,  not  infrequently  bring  about  the 
cessation  of  colic,  but  in  another  group  of  cases  it  seems  al- 
most impossible  by  any  means  in  one's  power  to  reduce  the 
severity  and  number  of  attacks.  Before  directing  treat- 
ment against  the  coUc  itself,  one  should  be  sure  that  this 
alone  is  to  blame  for  the  crying  of  the  child.  A  spoiled 
child  when  refused  attention  may  set  up  such  a  cr}-  as  to 
closely  simulate  colic.  In  such  cases  the  thing  most 
to  be  desired  is  discipline;  nor  can  we  expect  to  get  results 
in  a  few  days  even  by  the  most  rigid  attention  to  rules. 


114  INFANT   FEEDING 

Again,  the  syphilitic  cry,  as  described  by  Sisto,^  may  be  a 
source  of  error,  and  the  condition  be  relieved  by  mercurials. 
Yet,  after  all  these  have  been  considered,  we  must  admit 
that  a  majority  of  these  cases  are  essentially  colic  and  must 
be  treated  as  such. 

Two  distinct  types  of  colic  can  be  recognized:  one  in 
which  the  symptoms  appear  to  be  due  to  accumulation  of 
gas;  the  other,  where  the  underlying  condition  is  a  spasm 
of  the  intestinal  wall.  Though  an  apparently  different 
condition,  the  latter  is  really  only  a  more  severe  circula- 
tory disturbance  of  the  wall  of  the  alimentary  tract  than 
the  former.  That  condition  where  gas  is  predominant 
shows  first  a  tendency  to  accumulation  of  gas  in  the 
stomach.  To  expel  this  gas  the  child  can  be  held  to  the 
shoulder  or  placed  on  its  stomach  across  the  lap,  in  which 
positions  it  most  easily  raises  the  accumulated  gas.  For 
this  condition  stomach  washing  and  a  long  interval  between 
nursings,  with  a  limitation  of  the  time  at  the  breast,  in 
order  to  reduce  the  fat,  will  eventually  bring  complete 
relief.  Where  the  gas  is  in  the  intestine,  as  evidenced  by 
the  passage  of  flatus,  relief  is  best  obtained  by  colonic 
flushing:  the  tube  should  pass  well  up  into  the  colon  and 
water  at  about  98°  F.  be  used.  Since  the  underlying 
condition  is  probably  a  congestion  of  the  intestines,  the 
blood  should  be  brought  to  the  surface  by  means  of  hot 
applications  to  the  extremities  and,  perhaps,  turpentine 
stupes. 

In  some  cases  when  one  is  giving  a  flushing  the  intestines 
seem  to  come  down  and  grasp  the  tube,  then  relax,  allow- 
ing the  tube  to  pass  on;  this  undoubtedly  is  due  to  a  spasm 
1  Arch,  de  Med.  Inf.,  1910,  xiv,  589. 


Fig.  6. — Method  of  giving  i  olonic  flushing. 


NUTRITIONAL   DISTURBANCES   IN   BREAST-FED   INFANT      115 

of  the  musculature.  If  the  means  given  above  fail  to  relieve 
this,  one  must  resort  to  sedatives,  and  none  of  these  are  of 
any  avail  except  opium.  All  care  possible  must  be  taken 
in  the  dosage  of  this  drug;  since  infants  are  peculiarly 
susceptible  to  its  action.     Holt  advises  doses  as  follows: 


Preparations  used. 


Paregoric 

Deodorized  tincture. . 

Dover's  powder 

Morphin 

Codein 


One  month. 


m 

gr.  is 
gr.  tAtt 
gr.  shs 


Three 
months. 


gr.  T^ 
gr.  ^u 
gr.  ^(j 


One  year. 


TIJJV  to  X 
tiKj  to  ^ 
gr.  i  to  ^ 
gr.  ^h 
gr.  ^ 


Five  years. 


TtJJXXX  to  xl 

TTjij  to  iij 
gr.  ij  to  iij 
gr.  ^  to  ^ 
gr.  'Aj  to  i 


But  in  the  experience  of  the  writer  somewhat  larger  doses 
have  proved  safe,  and  were  necessary  in  order  to  control 
the  pain. 

At  times  hot  water  and  peppermint-water  seem  to  do 
good,  but  their  action  is  so  transient  and  irregular  as  to 
allow  some  doubt  as  to  their  efficacy. 

OTHER  WUTRITIONAL  DISTURBANCE 

Decomposition  or  marasmus  is  very  rare  in  breast-fed 
infants  as  a  result  of  gastro-intestinal  disturbances  per  se, 
but  may  occur  as  a  result  of  intercurrent  affections,  though 
this  is  not  common.  Its  discussion  will  be  reserved  for 
those  chapters  on  artificial  feeding. 

Intoxication  is  likewise  rare,  and  will  be  taken  up  in 
the  same  way. 


PART   III 
ARTIFICIAL   FEEDING 


CHAPTER  X 

FOODS  USED  IN  ARTIFICIAL  FEEDING  OF  INFANT » 

In  the  artificial  nourishment  of  the  infant  that  food 
which  is  most  important  is  milk.  In  the  majority  of  cases 
cows'  milk  is  the  only  one  to  be  considered,  though  in  some 
places  goats'  milk  is  used  in  rather  large  quantities,  and 
in  others  mares'  or  asses'  milk  is  occasionally  used.  Though 
other  milks  may  be  of  some  interest,  cows'  milk  is,  by  all 
means,  the  most  important  and,  therefore,  deserving  of 
our  greatest  attention. 

COWS'  MILK 
Requisites  for  a  Good  Cows'  Milk. — ^'liile  it  is  always 
desirable  to  meet  ideal  conditions  in  respect  to  the  proper 
precautions  to  be  taken  in  procuring  a  good  cows'  milk, 
still  it  is  very  frequently  impossible  to  do  so.  The  attempt 
may  be  disastrous  in  two  ways :  first,  it  may  raise  the  price 
of  milk  so  high  as  to  make  it  a  hardship  for  poor  parents 
to  buy  it  for  their  babies;  and  second,  which  is  of  much 
graver  consequence,  the  publicity  involved  in  obtaining 
an  ideal  supply  of  milk  for  a  large  community  may  cause 

1  For  a  more  exhaustive  work  on  milk,  etc.,  see  Hygienic  Laboratory 
Bulletin,  No.  41. 
116 


FOODS    USED    IN    ARTIFICIAL   FEEDING    OF   INFANT       117 

the  more  ignorant  classes  (therefore  those  to  whom  the 
most  infants  belong)  to  refuse  to  give  an  impure  milk  to 
their  babies,  and  resort  to  the  disastrous  expedient  of  at- 
tempting to  nourish  them  on  some  such  foods  as  condensed 
or  malted  milk.  For  these  reasons  it  seems  to  me  that  we 
will  attain  our  ends  with  much  more  certainty  and  with 
much  less  loss  of  life  if  we  work  by  evolution  rather  than 
by  revolution,  remembering  that  while  clean  milk  is  very 
desirable  when  feeding  infants,  there  are  other  problems 
of  far  greater  value  which  can  be  solved  with  the  means  in 
our  possession. 

The  secret  of  good  cows'  milk  lies  in  cleanliness  and  in 
the  health  of  the  herd.  The  best  milk  is  herd  milk,  be- 
cause of  the  greater  regularity  in  the  percentage  of  the 
various  constituents.  As  a  rule,  it  is  better  that  the  cows 
should  not  be  Jerseys,  because  of  the  delicate  constitu- 
tion of  the  breed,  hence  predisposing  to  tuberculosis,  and 
because  of  the  high  fat-content,  which  is  not  desirable. 
Every  cow  furnishing  milk  for  infant  feeding  should  be 
tuberculin  tested.  This  is  an  extremely  hard  law  to  enforce 
in  some  communities,  but  every  precaution  possible  should 
be  taken  in  this  direction.  The  stable  in  which  the  cows 
are  kept  should  be  on  high  ground,  away  from  pig-pens, 
chicken-yards,  etc.,  and  should  have  good  flooring,  pref- 
erably cement;  it  should  be  well  ventilated  and  lighted, 
and  so  constructed  that  it  can  be  thoroughly  and  easily 
cleaned.  The  cows  themselves  should  be  kept  clean  and 
the  udders  washed  well  before  each  milking.  The  food 
should  never  consist  of  brewery  refuse,  etc. 

It  is  veiy  important  that  the  milker  be  healthy  and  clean 
in  his  person.    We  should  be  sure  that  he  has  no  infectious 


118  INFANT   FEEDING 

disease,  such  as  tuberculosis,  typhoid  fever,  diphtheria, 
scarlet  fever,  etc.  Where  possible,  he  should  wear  clean 
white  linen  for  milking,  should  wash  the  hands  thoroughly, 
and  be  careful  not  to  handle  any  articles  unnecessarily. 
All  these  precautions  can  be  taken  by  any  reasonably 
intelligent  individual,  and  will  add  greatly  to  the  cleanli- 
ness of  the  milk. 

The  milk  should  be  collected  in  utensils  which  have  been 
sterihzed  or  at  least  scalded,  immediately  cooled  and  sealed, 
and  kept  in  this  condition  until  delivery.  These  precau- 
tions are  especially  necessary  if  the  distance  of  transporta- 
tion is  long. 

Perhaps  the  greater  factor  in  procuring  a  good  milk  for 
infants'  use  is  the  period  of  time  which  elapses  between 
milking  and  delivery.  In  large  cities  this  is  seldom  less 
than  twenty-four  hours,  and  hence  unusual  precautions 
must  be  taken  in  order  to  deHver  a  sufficiently  pure  milk. 
The  shorter  this  period,  ceteris  paribus,  the  cleaner  the 
milk,  i.  e.,  the  lower  the  bacterial  count.  At  the  time 
of  consumption  the  number  of  bacteria  per  cubic  centi- 
meter should  not  be  over  20,000  to  30,000,  preferably  not 
over  10,000.  In  the  larger  communities  this  is  rarely 
possible,  and,  except  in  the  certified  milks,  a  count  of 
several  hundred  thousand  is  more  often  found.  The  milk 
must  be  free  from  all  pathogenic  micro-organisms. 

Milk  for  the  infant  must  be  free  from  preservatives  and 
all  other  artificial  contaminations.  It  must  have  a  stable 
percentage  of  the  various  constituents,  especially  must  the 
fat  (the  most  variable  of  all  constituents)  be  3.5  to  4  per 
cent.  If  the  precautions  above  cited  are  taken,  we  will 
obtain  a  milk  sufficiently  good  so  that  we  may  ascribe  any 


FOODS    USED    IN    ARTIFICIAL   FEEDING   OF   IXFAXT      119 

nutritional  disturbance  in  the  infant  not  to  decomposition 
of  the  milk,  but  to  errors  in  diet  or  to  constitutional  affec- 
tions. 

Chemical  Composition  and  General  Characteristics  of 
Cows'  Milk. — Cows'  milk  has  a  specific  gravity  of  1.027 
to  1.035.  Immediately  after  milking  it  is  amphoteric; 
later,  distinctly  acid.  The  acidity  is  primarily  due  to  the 
acid  phosphates  and  carbonic  acid,  and  secondarily,  to  de- 
composition of  the  milk-sugar  by  the  bacteria  of  the  milk. 

The  chief  constituent  of  milk  is  water.  Of  the  organic 
materials,  fat,  protein,  and  carbohydrate  are  present. 
The  fat  is  chiefly  in  the  form  of  olein,  palmitin,  and  stearin, 
with  some  of  the  volatile  acids.  The  protein-content  con- 
sists in  large  part  of  caseinogen,  with  a  smaller  quantity  of 
lactalbumin,  a  trace  of  lactoglobulin,  and  some  other  pro- 
teins. The  carbohydrate  is  practically  all  in  the  form  of 
lactose. 

The  inorganic  constituents  consist  of  phosphates,  sul- 
phates, chlorin,  calcium,  magnesium,  sodium,  potassium, 
and  iron.     A  small  amount  of  citric  acid  is  found. 

The  schemes  of  Van  Slyke  and  of  Babcock,  as  shown  in 
the  Hygienic  Laboratory  Bulletin,  No.  41,  p.  314,  show 
graphically  the  various  constituents  and  their  percentages: 


Milk,  100 


Water,  87. 1 

Solids,  12.9- 

100.0 

12.9 

(Carbon  dioxid. 
Nitrogen. 
Oxygen. 


VAN  SLYKE. 

Fat,         3.9 

Solids,  [Nitrogen  [Casein,         2.5 

not  fat,  9.0'    compounds,  3.2]  Albu- 

Milk-sugar,    5.1  [     min,  etc.,  0.7 

Ash  (salts),     0.7  

3.2 

9.0 


120 


INFANT   FEEDING 


BABCOCK. 
Milk,  100 

Butter-fat,  3.6 

Glycerids  of  insoluble  and  non- 
volatile acids 3.3 

Olein 
Palmitin 
Stearin 
Myristin 
Butin  (trace) 
Glycerids  of  soluble  and  volatile 

acids 0.3 

3.6 

Butyrin 
Caproin 

Caprylin  (trace) 

Caprinin  (trace) 

Milk-serum,  96.4 

Containing  nitrogen 

Casein 3.0 

Albumin 0.6 

Lactoglobulin  ^ 
Galactin  >  0.2 

Fibrin  (trace)  ) 

3.8 

Milk-sugar 4.5 

Citric  acid 0.1 

Potassium  oxid  .0.175' 
Sodium  oxid....  0.070 
Calcium  oxid.  .  .0.140 
Magnesium  oxid  0.017  r"  Ash. 0.7 

Iron  oxid 0.001 

Sulphur  trioxid. .  0.027 
Phosphoric 

pentoxid 0.170 

Chlorin 0.100 


^Fat, 


3.6 


.3.8 


9.1 


Total 
soUds,  12.7 


SoUds, 
not  fat,    9.1 


12.7  J 


0.7 
Water '. 87.3 


100.0 


For  general  use  we  may  regard  the  fat  as  present  in  3.5 
to  4  per  cent.;  the  protein,  3.8  to  4  per  cent,  (casein,  3  per 


FOODS    USED    IN   ARTIFICIAL   FEEDING   OF  INFANT      12^ 

cent. ;  albumin,  .4  to  1  per  cent.) ;  the  milk-sugar,  4  to  4.5 
per  cent. ;  the  salts,  about  .7  per  cent. 

In  addition  to  the  constituents  cited  above,  the  milk 
contains  a  number  of  enzymes  (diastase,  galactase,  lipase, 
salol-splitting  ferment,  oxidizing  ferments,  i.  e.,  catalase 
and  peroxidase,  reductase).  The  function,  if  any  exists, 
of  these  substances  is  unknown.  Whether  if  rendered  in- 
active {e.  g.,  by  heat)  the  effect  is  deleterious,  is  as  yet  not 
known. 

Bacterial  Content  of  Milk. — The  number  of  bacteria  in 
milk  is  an  index  on  its  freshness,  and  the  precautions  taken 
in  milking  and  marketing  the  product.  A  count  of  over 
100,000  bacteria  per  cubic  centimeter  is  certainly  not  fit 
for  use  in  nourishing  the  infant,  but  a  count  of  10,000  or 
below  is  desirable.  The  bacteria  may  be  divided  into  two 
classes — pathogenic  and  non-pathogenic.  In  the  former 
group  may  be  placed  such  organisms  as  the  tubercle  bacil- 
lus, the  typhoid  bacillus,  and  the  diphtheria  bacillus. 
Milk  containing  these  organisms  is  a  direct  source  of  danger 
to  the  indi\adual  to  whom  it  is  supplied  as  food,  hence  their 
presence  is  definitely  detrimental  and  should  be  prevented 
in  all  milk  supphed  to  infants.  Rosenau^  has  determined 
that  by  heating  the  milk  to  60°  C,  and  maintaining  it 
at  that  temperature  for  twenty  minutes,  these  and  all 
other  pathogenic  organisms  hkely  to  be  present  are  des- 
troyed, and  the  milk  is  rendered  free  from  the  possibility 
of  contagion  from  these. 

The  non-pathogenic  bacteria,  such  as  staphylococci, 
streptococci,  lactic  acid  bacilli,  etc.,  are  a  source  of  danger, 
not  because  of  their  direct  action  upon  the  human  organ- 

^  Hygienic  Lab.  Bull.,  No.  42. 


122  INFANT   FEEDING 

ism,  but  because  of  their  decomposing  action  on  the  milk 
itself,  which  renders  it  unfit  for  use.  As  to  just  what  the 
substances  thus  formed  are  which  cause  the  difficulty  it 
is  not  definitely  determined,  but,  in  all  probability,  the 
fatty  acids  are  largely  to  blame.  The  vast  bulk  of  the 
bacteria  in  average  milk  is  made  up  of  such  organisms, 
and  the  bacterial  count  is  an  estimate  of  their  number  and, 
to  a  great  degree,  of  their  activity,  since  the  process  of 
growth  is  directly  dependent  on  their  biologic  character- 
istic of  being  able  to  decompose  and  assimilate  the  milk 
constituents.  Whether  the  foreign  protein  introduced 
in  the  milk  by  their  enormous  increase  is  deleterious  to 
the  human  body  is  a  subject  for  future  investigation. 

Adulteration  of  Milk. — Adulteration  of  milk  is  carried 
on  in  three  ways:  first,  by  thinning  the  milk;  second,  by 
thickening  the  milk;  third,  by  addition  of  preservatives  or 
coloring-matter.  Thinning  the  milk  is  accomplished  by 
either  skimming  or  watering.  Though  highly  undesirable 
and  palpably  fraudulent,  so  far  as  the  infant  is  concerned, 
these  processes  are  not  dangerous,  so  long  as  they  are 
carried  on  in  a  sterile  manner.  Thickening  of  the  mUk 
is  seldom  resorted  to,  and  deserves  no  further  attention. 
Coloring-matters  are  sometimes  used  in  thinned  milk  to 
give  the  idea  of  higher  percentage  of  solids.  Of  all  means 
of  adulteration,  that  most  important,  from  our  standpoint, 
is  the  addition  of  preservatives.  These  in  themselves  may 
be  dangerous,  and  by  their  addition  they  keep  down  the 
bacterial  count  in  a  milk  which  may  contain  much  harmful 
sediment,  such  as  pus  and  manure.  Of  the  milk  preserva- 
tives, formaldehyd,  borax  and  boric  acid,  and  sodium  bicar- 
bonate are  most  frequently  used.      It  is  probable  that  these 


FOODS   USED   IN   ARTIFICIAL   FEEDING    OF  INFANT      123 

preservatives,  in  the  dilution  usually  employed,  have 
little  or  no  effect  on  digestion,  but  at  the  same  time  a  milk 
which  it  is  found  necessary  to  "  preserve  "  in  this  fashion 
must  primarily  be  contaminated,  and  is,  therefore,  unfit  for 
use. 

Sediment  of  Milk. — ^The  sediment  of  milk  consists  of 
two  sots  of  constituents,  those  of  the  milk  proper  and 
foreign  material.  The  latter  consists  principally  of  manure, 
etc.,  and  is  the  more  abundant  the  more  unhygienic  the 
conditions  under  which  the  milk  is  obtained.  Of  the  for- 
mer, fat-globules  and  bacteria  constitute  a  considerable 
portion. 

Epithelial  cells  and  an  occasional  leukocyte  are  likely  to 
be  present  in  any  specimen  of  milk.  Pus-cells  in  great 
abundance  are  strongly  indicative  of  inflammation  of  the 
udders,  and  the  herd  should  be  carefully  investigated  in 
order  to  eliminate  such  contamination. 

Lewis^  states  that  if  the  sediment  be  studied  with  the  use 
of  a  good  blood-stain  the  following  constituents  will  be  noted : 
Epithelial  or  endothelial  cells,  polymorphonuclear  neutro- 
philes,  eosinophiles,  lymphocytes,  and  red  blood-corpuscles. 
He  thinks  that  clumps  of  polynuclears  and  eosinophiles  to- 
gether with  long  chain  streptococci  mean  mammary  gland 
trouble  in  the  cow.  Absence  of  streptococci,  however,  does 
not  mean  that  such  is  not  present. 

"  Germicidal "  Action  of  Milk. — In  plating-out  milk  to 
make  a  bacterial  count  it  has  been  noticed  that  the  fresh 
milk  gives  more  colonies  than  docs  that  which  has  stood 
a  few  hours.  At  first  it  was  concluded  that  tliis  meant  a 
reduction  in  the  number  of  bacteria,  and  hence  a  certain 

1  Amer.  Jour.  Dis.  of  Child.,  1913,  vi,  225. 


124  ENFANT  FEEDING 

germicidal  property  of  the  milk.  Rosenau  has  shown,  how- 
ever, that  the  reduction  is  only  apparent,  and  is,  in  fact, 
due  to  the  presence  of  agglutinins  causing  many  bacteria 
to  produce  but  one  colony.  This  agglutination  is  often 
specific  in  its  action,  acting  on  one  group  of  bacteria  but 
not  on  another.  That  the  milk  in  the  fresh  state,  however, 
possesses  some  inhibitive  action  on  bacteria  is  shown  by 
boiling,  after  which  the  bacterial  growth  is  much  more 
rapid  than  before. 

Pasteurization  and  Sterilization  of  Milk. — For  the  pur- 
pose of  ehminating  the  danger  (direct  or  indirect)  of  bacte- 
rial action,  heating  the  milk  has  been  resorted  to.  The  sim- 
plest form  of  doing  this  is  by  pasteurization,  in  which 
process  the  milk  is  heated  to  60°  to  65°  C.  (140°-150°  F.) 
for  thirty  minutes.  If  no  thermometer  is  at  hand,  a  suffi- 
ciently accurate  temperature  may  be  had  by  heating  the 
milk  until  a  scum  forms  on  it,  and  maintaining  it  at  that 
temperature  for  the  time  mentioned.  Pasteurization  kills 
aU  the  pathogenic  bacteria  and  from  98  to  99  per  cent,  of 
the  other  bacteria.  After  pasteurization  there  is  less  in- 
hibition to  bacterial  growth  than  in  raw  milk.  The  chem- 
ical changes  in  the  milk,  so  far  as  known,  are  unimportant 
(Rupp).^  Commercial  pasteurization  is  not,  as  a  rule,  to  be 
trusted,  because  it  may  be  carried  out  on  very  bad  milk,  and 
then  be  inadequately  done.  The  time  of  delivery,  too,  may  be 
so  long  after  the  heating  that  bacterial  growth  is  very  great. 

Sterilization  consists  in  boiling  the  milk  for  from  five  to 

twenty  minutes.     By  doing  this  we   destroy  all  bacteria 

and  their  spores,  but  at  the  same  time  we  destroy  the  power 

of  the  milk  to  inhibit  their  growth,  and  any  contamina- 

1 U.  S.  Dept.  Agric.  BuU.,  No.  166. 


FOODS    USED    IN    ARTIFICIAL   FEEDING   OF   INFANT      125 

tion  will  be  followed  by  marked  increase  of  the  number  of 
bacteria  in  a  f(nv  hours.  The  chemical  changes  produced 
by  sterilization  are  very  marked.  Czerny  and  Keller 
enumerate  them  as  follows: 

1.  The  milk-sugar  is  caramelized  under  the  formation  of  acid  (lactic 
acid). 

2.  The  coagulated  casein  and  albumin  are  brought  by  the  acid  to 
an  early  precipitable  condition. 

3.  The  rennet  action  on  milk  is  very  much  impaired  through  the 
fact  that  the  calcium  salts  are  in  part  rendered  insoluble. 

4.  The  milk  gases,  especially  carbonic  acid,  are  expelled. 

5.  The  ferment  action  of  the  milk  is  destroyed. 

6.  The  fat  in  part  separates  from  its  emulsified  state. 

7.  The  lecithin  is  split  up  and  the  other  organic  phosphorus  com- 
binations of  the  milk  are  more  or  less  changed  into  inorganic. 

8.  Boiled  milk  undergoes  putrefaction,  raw  milk  does  not. 

9.  The  taste  of  the  milk  is  disagreeablj'  changed. 

10.  The  antiseptic  and  antitoxic  properties  of  the  milk  are  lost. 

11.  Hydrogen  sulphid  is  recognizable  if  the  milk  is  boiled  longer 
than  five  minutes. 

According  to  the  investigations  of  Lane-Claj'pon^  there  is 
no  scientific  or  practical  reason  for  believing  that  in  infant 
feeding  boiled  milk  is  in  any  way  inferior  to  raw.  The  ex- 
perience of  Brenneman*  goes  to  show  conclusively  that  the 
curd  from  raw  milk  is  much  harder  and  larger  than  is  that 
from  boiled  milk. 

CONDENSED   MILK 

This  is  prepared  by  evaporation  of  milk  in  vacuo.  To 
some  preparations  cane-sugar  in  large  amounts  is  added. 
This  latter  is  known  as  the  "  sweetened  "  variety,  and  is 
that  most  used  in  infant  feeding.  In  its  preparation  1\ 
pounds  of  cane-sugar  are  added  to  each  gallon  of  milk  and 
the  whole  evaporated.    The  finished  product  has  a  density 

^  Report  to  Local  Government  Board,  New  Series,  No.  63,  London, 
1912. 

2  Jour.  Amer.  Med.  Assoc,  1913,  Ix,  575. 


126 


INFANT   FEEDING 


of  about  1.28,  weighs  one-third  of  the  original,  and  is  ^  of 
its  volume,  i.  e.,  1  gallon  of  milk  makes  2|  pints  of  condensed 
milk.  (Sometimes  commercial  glucose  is  substituted  for 
the  whole  or  part  of  the  cane-sugar.)  The  product  thus  ob- 
tained is  not  sterilized,  since  the  concentration  is  so  great 
that  bacteria  do  not  grow,  and  since  most  of  the  bacteria 
have  already  been  killed  in  the  process  of  evaporation  in 
vacuo.  The  composition  of  sweetened  condensed  milk  is 
approximately  as  follows*. 


Water 24  to  30  per  cent. 


Fat. 


{' 


0.36  to  1 
9  to  11 

Milk-sugar 14  to  16 

Cane-sugar 32  to  41 

Proteins 9  to  12 

Ash 2  to  2.5 


if  made  from  separated  milk, 
if  made  from  whole  milk. 


The  caloric  value  for  that  made  from  separated  milk 
is  about  55  calories  per  ounce,  for  that  made  from  whole 
milk  about  85  calories  per  ounce. 

The  unsweetened  product  is  prepared  in  the  same  way, 
but  without  the  addition  of  sugar.  It  must  be  steriHzed 
to  be  properly  preserved.  The  composition  is  about  as 
follows: 

Water '. 62  to  69  per  cent. 

Fat 9  to  12         " 

Milk-sugar 13  to  15.5      " 

Proteins 9  to  10         " 

Ash 1.6  to  2.3        " 

Caloric  value,  about  58  calories  per  ounce. 

In  considering  condensed  milk  as  a  food  for  infants 
many  disadvantages  can  be  noted.  The  process  denatur- 
izes  the  milk,  thus  robbing  it  of  one  of  its  properties  the 
importance  of  which  for  infant  feeding  is  not  as  yet  clear. 
From  a  commercial  standpoint  it  wiU  be  readily  recognized 


FOODS    USED    IN    ARTIFICIAL   FEEDING    OF  INFANT      127 

by  one  who  will  stop  to  think  that  in  order  to  make  the 
sale  of  condensed  milk  profitable  a  very  inferior  grade  of 
milk  must  be  used.  The  presence  of  cane-sugar  in  such 
large  amounts  and  the  low  fat^content  in  so  many  of  the 
condensed  milks  on  the  market  give  a  food  which  in  its 
composition  is  anything  but  desirable.  In  examining  the 
sediment  of  condensed  milk  as  obtained  by  high-speed 
ccntrifugalization,  McCampell*  was  able  to  determine  that 
large  quantities  of  manure  were  present,  and  that  in  at 
least  some  of  the  specimens  tubercle  bacilli  could  be  demon- 
strated by  staining  and  inoculation  experiments. 


WHEY 

Whey  is  prepared  by  the  addition  of  rennet  to  the  milk, 
which  is  kept  at  a  temperature  of  about  40°  C.  (100°-105° 
F.)  for  an  hour  to  an  hour  and  a  half,  then  strained  through 
a  sterile  cloth.  The  fluid  is  the  whey.  (If  the  whey  is 
not  desired  and  a  fine  soft  curd  is  sought,  it  is  better  to  use 
chymogen  [Armour  &  Co.],  a  teaspoonful  to  the  quart, 
and  allow  to  drain  for  an  hour  to  an  hour  and  a  half). 
The  chemical  composition  of  whey  is,  according  to  Holt's 
table,2  as  follows: 

WHEY 


Average 

46  analyses 

(Koenig). 

From  whole 

milk 
(Adriance). 

From  fat-free 

milk 

(Adriance). 

Protein 

0.86 
0.32 
4.79 
0.65 
93.38 

0.94 
0.96 
5.49 
0.48 
92.13 

1.17 

Fat 

0.04 

Sugar 

5.36 

Salts 

0.52 

Water 

92.91 

'  Personal  communication.    Work  done  in  Bacteriological  Labora- 
tory of  Ohio  State  University. 

2  Diseases  of  Infants  and  Children,  1906,  161. 


128  INFANT   FEEDING 

If  a  fine  curd  is  desired  it  is  better  to  boil  the  milk  before 
the  rennet  is  added  and  then  continue  as  above  (Brenne- 
man).^     (See  also  Albumin-milk.) 

The  best  carbohydrate  fluid  in  which  to  suspend  curds 
is  a  rather  thick  arrow-root  water  (IJ  tablespoonfuls  to 
the  quart  of  water). 

Whey  has  been  used  rather  extensively  by  the  followers 
of  the  percentage  method,  with  the  idea  that  the  protein, 
which  consists  largely  of  lactalbumin,  is  more  easily  digested 
than  is  the  casein.  In  this  treatise  very  Httle  if  any  use 
of  whey  will  be  advised,  but  more  notice  will  be  taken  of  the 
curd,  for  reasons  to  be  given  later. 

PEPTONIZATION 

This  is  much  less  used  than  formerly,  due  to  the  decided 
change  of  opinion  in  regard  to  the  harmfulness  of  the 
protein.  According  to  the  idea  of  the  writer  it  is  never 
necessary.  If  it  is  desired  to  peptonize  milk  one  should  add 
the  tube  of  pepsin  to  the  amount  of  milk  designated  in  the 
directions  (usually  1  pint  or  1  quart),  allow  to  stand  at 
40°  C.  (100°-105°  F.)  for  twenty  minutes  if  complete 
peptonization  is  needed,  then  bring  to  a  boil  or  keep  on 
ice.  One  can  regulate  the  amount  of  peptonization  by 
decreasing  the  length  of  time  for  the  action  of  the  ferment 
to  ten,  five,  etc.,  minutes. 

CHANGE  OF  FAT-CONTENT 

For  changing  the  fat-content  of  the  food,  cream  may  be 
added  to  the  milk  mixture.  Cream  is  designated  as  12,  16, 
24,  or  32  per  cent.,  according  to  the  fat  percentage.     Fat- 

1  Amer.  Jour.  Dis.  of  Child.,  1911,  i,  341. 


FOODS    USED    L\    ARTIFICIAL   FEEDING    OF   INFANT      129 

free  or  skimmed  milk  is  prejiared  either  by  removing  the 
gravity  cream  or  by  centrifuge.  The  latter  means  is  the 
most  satisfactor}'.  In  all  skimmed  milk  a  certain  amount 
of  fat  still  remains.  In  the  centrifuge  variety  this  amounts 
to  0.2  to  0.3  per  cent.,  while  in  that  prepared  by  the  re- 
moval of  gravity  cream  it  may  amount  to  1  per  cent,  or 
even  more.  All  commercial  skimmed  milk  is  prepared 
with  the  centrifuge. 

So  far  as  the  writer  knows,  no  literature  on  homogenized 
milk  has  appeared  in  this  country. 

HOMOGENIZATION 

Homogenization  con.sists  in  an  emulsification  of  the 
milk-fat  with  the  idea  of  reducing  the  larger  fat-globules  of 
cows'  milk  to  the  same  size  of  the  fine  globules  in  women's 
milk.  For  this  purpose  special  machines  are  used.  Birk/ 
after  a  trial  of  this,  comes  to  the  conclusion  that  for  well 
and  sick  infants  it  possesses  no  advantage  over  milk  not 
so  treated. 

BUTTERMILK 

Buttermilk  has  been  extensively  used  both  in  this  country 
and  abroad.  To  1  quart  of  fat-free  milk  about  8  ounces  of 
water  is  added,  and  a  tablet  of  lactic  acid  bacilli  is  crushed 
and  dropped  into  the  mixture,  the  whole  being  allowed  to 
stand  for  twenty-four  houre  at  room  temperature,  at  the 
end  of  which  time  it  is  ready  for  use.  There  seems  to 
be  little  difference  in  the  action  of  the  various  prepara- 
tions of  lactic  acid  bacteria  (Heineman).-     If  one  wishes 

1  Monatsschr.  f.  Ivindcrheilk.,  1908,  \-ii,  129. 

2  Jour.  Amer.  Med.  Assoc,  1909,  lii,  372. 
9 


130  INFANT   FEEDING 

to  continue  the  preparation,  it  is  well  to  do  so  by  transfer- 
ing  a  teaspoonful  of  the  buttermilk  each  day.  This  seems 
to  give  a  somwehat  more  even  result.  In  spite  of  the 
greatest  care  contamination  will  occur,  so  that  it  is  always 
advisable  where  possible  to  run  two  cultures  at  the  same 
time. 

COMPOSITION   OF  BUTTERMILK^ 

Water 90.62 

Casein 3.78 

Fat.... 1.25 

Milk-sugar 3.38 

Lactic  acid 0.32 

Ash 0.65 

ALBUMIN-MILK 

Finkelstein  and  Meyer  advised  a  mixture  to  be  used  under 
certain  conditions  which  they  have  termed  albumin-milk 
(Eiweissmilch).  This  consists  in  mixing  the  curds  of  1 
quart  of  whole  milk  with  1  pint  of  buttermilk  made  from 
skimmed  milk,  and  making  the  whole  up  to  1  quart  with 
water.  By  doing  this  they  have  a  protein-rich  sugar 
and  salt-poor  food,  the  fat  quantity  being  relatively  large. 
The  difficulties  in  preparing  this  food  are  great,  and  lie  in 
two  directions:  first,  it  is  hard  to  procure  a  curd  so  fine  that 
it  mil  not  settle  to  the  bottom  of  the  mixture  and  clump; 
and,  second,  the  buttermilk  is  rarely  a  stable  product  for 
weeks  in  succession. 

The  writer  advises  the  following  method:  The  milk  may 
or  may  not  be  boiled  for  five  minutes;  if  boiled,  it  is  cooled, 
and  chymogen  (Armour  &  Co.),  a  teaspoonful  to  the  quart, 
is  added.  This  is  allowed  to  stand  one  hour  at  40°  C.  (100°- 
105°  F.),  and  is  then  strained  through  a  sterile  cheese-cloth 

^  BIythe,  Foods  and  Their  Composition,  London,  1909. 


Fiji.  S. — Infants'  diet  kitchen  for  small  hosjiifal;  of  much  service  in  pre- 
paring more  complicated  formuUc  (Provident  Hospital,  Chicago). 


FOODS    USED    IN   ARTIFICIAL   FEEDING   OF  INFANT      131 

bag,  and  allowed  to  drip  for  one  and  one-half  hours.  It  is 
then  pressed  through  a  colander  three  times  together  with 
the  buttermilk,  water  added  to  the  required  amount,  and 
beaten  vigorously  in  a  small  churn.  In  giving  tliis  milk,  if 
there  is  a  tendency  to  clumping,  the  whole  should  be  shaken 
well;  after  which  the  bottle  should  be  placed  in  warm  water 
only  long  enough  to  take  the  chill  off  the  milk;  any  more 
vigorous  heating  will  cause  the  curds  to  clump  at  the  bottom 
of  the  bottle  in  large  masses. 

COMPOSITION  OF  ALBUMIN-MILK 

FiNKELSTEIN    AND   MeTER.  BiRK. 

Protein 3.0  per  cent.  1.9  to  2.6  per  cent. 

Fat 2.5         "  0.9  to  2.7         " 

Milk-sugar 1.5         "  (  Average  1.3  per  cent. 

Ash 0.5         "  (High      3.6 

Two  modifications  of  albumin-milk  have  been  tried.  The 
one  known  as  protein  milk  (Wilcox,  Hill,  and  Hoobler^  varies, 
in  that  instead  of  whole  milk  fat-free  milk  is  used  for  the 
curd.  The  casein  enriched  cows'  milk  of  Heim  and  John^  is 
prepared  by  the  use  of  a  pint  of  whole  milk  instead  of  a 
pint  of  buttermilk. 

The  caloric  values  of  milk  and  its  derivations  are  about 
as  follows: 

1  ounce  whole  milk  (4  per  cent.) 21  calories. 


cream  (16  per  cent.) 54 

fat-free  milk 11 

buttermilk 10 

whey 5  to  6 

albumin-milk 13 


» Amer.  Jour.  Die.  of  Child.,  1913,  v,  297. 
» Zeitschr.  f.  Kinderheilk.,  1912,  iv,  1. 


132  INFANT    FEEDING 

Of  the  other  milks  used  in  infant  feeding,  that  of  the 
goat  is  most  often  mentioned  in  this  country.  Goats' 
milk  has  been  advised  because  of  its  high  fat-content  and 
the  high  resistance  of  that  animal  against  tuberculosis. 

The  composition  varies  greatly  in  goats  of  different  breeds. 
From  Czemy-Keller's  tables  the  following  is  collected: 

Total  protein 2i  to  4J  per  cent. 

Fat 2    to  7 

Milk-sugar 2    to  5  " 

Salts itol         '  " 

Asses'  milk  is  certainly  but  little  used,  if  at  all,  in  this 
country.  Its  chief  chemical  characteristics  are  a  low  pro- 
tein- and  fat-  and  a  high  sugar-content. 

CARBOHYDRATES 

Next  in  importance  to  milk  and  its  derivatives,  for  the 
food  of  the  infant,  are  the  various  carbohydrates.  These 
may  be  divided  into  two  main  classes — the  sugars  and  the 
starches.  Of  the  more  commonly  used  starches  and  sugars 
the  ounce  weight  may  be  determined  conveniently  as  fol- 
lows in  the  form  of  level  teaspoonfuls: 

Milk-sugar 9 

Dextri  maltose 10 

Mellin's  food 11 

Horlick's  food 14 

Flour  BaU 12 

Barley-flour  (Robinson) 15 

The  following  table  of  the  composition  of  the  various  sugars 
and  starches  and  the  caloric  value  of  each  is  compUed  from 
Bulletin  No.  28,  United  States  Department  of  Agriculture, 
Office  of  Experiment  Station.    The  amounts   here  given 


FOODS    USED    IN    ARTIFICIAL   FEEDING    OF   INFANT       133 

are  of  especial  value  because  they  represent  determinations 
made  on  material  purchased  in  open  market: 


Water. 

Protein. 

Fat. 

Carbohy- 
drates. 

Aab. 

Calories 
I>er  ounce. 

Milk -sugar  (Merck)'.. 
Canc-suKar 

11.9 
7.3 
8.5 

13.8 
2.3 

10.5 

16.1 

8.6 

7.9 

2.2 
7.2 
6.1 
1.4 

100.0 
100.0 

72.8 
67.5 
68.0 
76.4 
97.5 

2.6 
1.9 
8.8 
0.5 

117.0 
117.0 

Barley  flour 

Oatmeal 

102.5 
117.0 

Rice  flour 

102.5 

Wheat  flour 

Arrow-root  flour 

102.0 
113.0 

Malt-sugar  is  not  used  in  the  pure  state.  In  place  of 
pure  malt-sugar  malt-extracts  are  used.  It  is  not  at  aU 
certain  that  the  action  of  malt-extract  is  due  entirely  or  in 
large  part  to  the  presence  of  malt-sugar,  as  at  first  sup- 
posed by  Keller.  The  composition  of  malt-extract,  ac- 
cording to  Culbreth,'  is  as  follows: 

Water 20  to  25  per  cent. 

Maltose 48  to  70         " 

Dextrin 2  to  16         " 

Diastase 1  to    2         " 

Protein 8  " 

Phosphoric  acid 0.3  to  0.4  per  cent. 

Lactic  acid 0.75  to  1.50      " 

Ash 1.5 

Keller  modified  this  by  neutralizing  the  malt-extract 
with  potassium  carbonate.     Caloric  value,  80  per  ounce. 

Another  preparation  of  malt-sugar  is  to  be  found  in 
dextrimaltose  (Mead,  Johnson  &  Co.).  This  consists  of 
maltose,  51  per  cent. ;  dextrin,  47  per  cent. ;  sodium  chlorid, 
2  per  cent.,  and  has  a  food  value  of  about  110  calories  per 

'  Not  in  bulletin,  but  added  to  complete  table. 
'  Materia  Medica  and  Pharmacology,  1906,  91. 


13^4  INFANT   FEEDING 

ounce.  It  is  wholly  soluble  and  contains  no  cellulose,  pro- 
tein, or  fat. 

Malt-ext'iact  is  more  laxative  than  are  other  malt-sugar 
preparations.  Seel^  ascribes  this  property  to  the  presence 
of  diastase. 

Wheat  flour  is  used  in  the  form  of  flour-ball,  which  is 
prepared  b}^  rolling  -i  cups  of  floiu'  in  a  piece  of  cheese- 
cloth, tjdng  tightly,  and  boiling  for  six  hom's.  then  dry. 
The  cloth  and  outside  crust  are  then  peeled  off,  the  chalky^ 
center  broken  into  small  pieces,  and  dried  in  an  oven  two 
to  four  hours.  This  is  then  groimd  up  and  sifted  imtil  it 
is  very  fine.  The  flour  thus  made  is  a  yery  good  carbohy- 
drate food  for  infants,  and  used  in  much  the  same  way  as 
barle}''  flour  or  oatmeal. 

Ruhrah^  ad\T.ses  the  more  extensive  use  of  the  Soja  bean 
in  infant  feeding.  He  has  prepared  a  flour  of  the  following 
composition: 

Protein  (N  x  6.25) 44.64  per  cent. 

Fat 19.43 

Mineral  matter 4.20 

[Moisture 5.26 

Crude  fiber 2.35 

Cane-sugar 9.34 

Non-nitrogenous  extract 14.78 

Starch None 

Reducing  sugars None. 

Caloric  value  is  120  to  the  ounce. 

Gruels  made  from  this  flour  settle  on  standing,  to  pre- 
vent which  it  is  well  to  add  barley,  oat,  or  wheat  gruel 
flour  before  cooking. 

A  vegetable  soup  which  can  be  used  as  a  diluent  is  made 

iZeitschr.  f.  Kinderheilk.,  1911  (Ref.).  i,  471. 
2  Jour.  Amer.  Med.  Assoc,  1910,  liv,  1664. 


FOODS   USED   IN   ARTIFICIAL   FEEDING   OF   INFANT     135 

in  the  following  way :  A  small  handful  of  spinach,  a  large 
beet,  and  two  medium-sized  carrots  are  chopped  fine,  and 
boiled  slowly  for  two  hours  in  a  quart  of  water,  strained, 
and  the  evaporation  loss  made  up.  This  corresponds  to 
the  vegetable  soups  advised  by  French  writers. ^ 

The  carrot  soup  advised  by  Moro^  is  made  by  boiling 
500  gm.  (1  pound)  of  carrots  in  200  c.c.  (^  pint)  of  water, 
and  then  add  enough  salted  meat  (beef)  soup  to  make  1 
liter  (quart). 

PROPRIETARY  FOODS 

There  is  no  question  that,  in  spite  of  the  efforts  of 
eminent  pediatricians  to  decry  them,  the  proprietary  infant 
foods  have  been  the  mainstay  of  the  general  practitioners. 
The  elaborate  means  which  their  manufacturers  have  em- 
ployed to  exploit  their  virtues  and  instruct  in  their  use 
may  be  regarded  as  largely  responsible  for  this.  So  long 
as  such  foods  are  used  by  the  physician  with  definite  indi- 
cations and  with  definite  ends  in  view,  and  so  long  as  their 
composition  is  definitely  known;  and,  again,  provided  they 
are  to  be  used  in  connection  with  milk,  then  we  may  say 
that  their  chief  dangers  are  eliminated.  But  what  is  done 
is  so  decidedly  opposite  to  this  that  the  whole  system  is  to 
be  condemned. 

In  a  great  many  cases  it  is  much  more  simple  to  advise 
the  use  of  a  proprietary  food  in  much  the  same  way  that 
we  advise  the  use  of  flour,  oatmeal,  or  barley.  When  so 
used  and  so  understood  the  proprietary  food  resumes  its 
natural  position,  that  of  an  adjuvant  in  the  preparation  of 
food  for  the  infant. 

1  Pehu,  L' Alimentation  dcs  Enfants  Malades,  Paris,  1908,  64. 
'  Mvinch.  med.  Wochenschr.,  1908,  Iv,  1637. 


136 


INFANT   FEEDING 


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FOODS    USED    IN    ARTIFICIAL    FEEDING    OF    INFANT      137 
OLIVE  OIL  AND  COD-LIVER  OIL 

Of  the  fatty  foods  other  than  milk,  ohve  oil  and  cod- 
liver  oil  are  most  frequently  used. 

Olive  oil  is  about  70  per  cent,  olein  and  is  a  pure  vege- 
table oil,  with  no  alkaloids  with  any  physiologic  action.  It 
has  been  advised  in  constipation,  but  is  of  very  doubtful 
value;  in  fact,  is  in  most  cases  distinctly  harmful  when  so 
used. 

Cod-liver  oil  is  much  used  in  pediatrics,  principally  in 
combination  with  phosphorus,  in  the  treatment  of  rickets. 
It  is  a  food  rather  than  a  drug,  and  should  be  so  consid- 
ered. It  consists  of  70  per  cent,  olein  and  25  per  cent, 
palmitin,  with  but  little  stearin,  cholesterol  0.5  to  1.5  per 
cent.,  and  iodin  content  .001  to  .002  per  cent.;  the  alkaloids, 
trimethylamin,  asellin,  and  morrhuin  are  present  in  small 
quantities;  traces  of  chlorin,  bromin,  phosphorus,  and 
sulphur  to  the  amount  of  0.3  per  cent.  Aside  from  its 
action  on  rickets,  cod-liver  oil,  in  certain  chosen  cases, 
seems  to  distinctly  increase  the  resistance  of  the  infant  to 
respiratory  infections. 

OTHER  FOODS  RICH  IN  PROTEIN 

Of  the  foods  rich  in  protein  other  than  cows'  milk  pro- 
tein, albumin- water,  eggs,  beef- juice,  and  such  protein  com- 
pounds as  nutrose,  somatose,  etc.,  may  be  mentioned. 

Alhumwr-water  is  made  by  adding  the  white  of  one  egg 
to  a  pint  of  sterile  water;  this  can  be  waiTned  slightly  and 
given  with  or  without  the  addition  of  salt.  Its  use  has  not 
been  so  widespread  recently,  but  it  still  fills  an  important 
need  in  the  treatment  of  acute  intestinal  disturbances. 

Beef-juice  can  be  made  in  either  of  two  ways:  A  round 
steak  may  be  very  slightly  broiled  and  the  juice  squeezed 


138  INFANT   FEEDING 

out;  or  a  pound,  of  finely  ground  steak  may  be  placed  in  a 
pint  of  steiile  water  and  kept  on  the  ice  over  night.  In 
the  morning  the  whole  is  strained  through  a  sterile  cheese- 
cloth bag,  and  the  liquid,  seasoned  and  shghtly  wanned, 
gives  an  excellent  beef-juice. 

Mention  should  be  made  of  beef-extract.  This  contains 
little  more  than  stimulating  extracts,  all  nourishment 
ha^TQg  been  removed  in  the  process  of  making.  Hence  the 
use  of  the  extract  is  not  to  be  advised  in  infant  feeding. 

Nutrose  and  somatose  deserve  only  to  be  mentioned. 
Nutrose^  has  the  following  composition:  Albumin,  65.2 
per  cent.;  nitrogen-free  substance,  20.15  per  cent.;  water, 
10.5  per  cent.;  ash,  4.15  per  cent.  Somatose^  is  a  water- 
soluble  derivation  of  meat^albumin. 

SALTS 

As  yet  no  attempt  to  reduce  the  amount  of  salts  in  the 
food  has  been  attempted  in  infant  feeding,  except  in  the  use 
of  albumin-milk  (see  later).  It  has,  however,  been  a  com- 
mon custom  to  add  alkalis,  such  as  lime-water  or  sodium 
bicarbonate,  to  the  food  to  render  it  more  like  woman's 
milk. 

The  advantage  or  disadvantage  of  such  additions  has 
never  been  demonstrated.  Sodium  citrate  has  been  added 
with  the  idea  of  softening  the  casein  curd.  T\Tiether 
necessars'  or  not,  it  has  apparently  attained  its  end  in  many 
cases.  Sodium  chlorid  is  usually  added  hi  the  preparation 
of  barley-water.  In  view  of  our  recent  knowledge  of  the 
influence    of    sodium    chlorid  on  the  bod)''  temperature, 

^Leng^ken,  Handb.  Neu.  Arzneiinittel,  Frankfort -on-Main,  1907, 
419. 

2  Ibid.,  561. 


FOODS   USED   IN   ARTIFICIAL   FEEDING   OF   INFANT 


139 


especially  in  infants  suffering  with  severe  nutritional  dis- 
turbances, it  would  seem  advisable  to  omit  it  when  the 
barley-water  is  prepared  for  such  cases. 

KOUMISS  AND   MATZOON 

Other  foods  occasionally  used  in  infant  feeding  are 
koumiss  and  matzoon.  The  composition  of  koumiss  is 
as  follows:' 


Water 

Milk-sugar 
Lactic  acid 
Casein .... 
Milk-fat .  . 
Alcohol . . . 

CO. 

Ash 


Ten  analyaes, 
Kunig. 


87.88 
3.76 
1.06 
2.83 
0.94 
1.59 
0.88 
1.07 


From  mares'  From  cows' 

milk,  I  milk, 

W.  Fleischman. ,  W.  Fleiachman. 


91.53 
1.25 
1.01 
1.91 
1.27 
1.85 
0.88 
0.29 


88.93 
3.11 
0.79 
2.03 
0.85 
2.65 
1.03 
0.44 


Forty-eight 

household, 

J.  A.  Wankiyn. 


87.32 
6.60 

2.84 
0.68 
1.00 
0.90 
0.66 


Koumiss  is  not  used  except  by  those  who  have  a  special 
regard  for  it.  It  has  never  attained  general  use  as  an  infant 
food. 

Of  matzoon,  the  same  may  be  said.  Its  composition  is 
as  follows:^ 

Protein 3.48 

Fat 3.49 

Milk-sugar 3.68 

Lactic  acid 0.90 

Alcohol  and  other  products  of  fermentation 0.13 

Mineral  salts 0.69 

Water 87.63 

100.00 

^  Blythe,  Foods  and  Their  Composition,  London,  1909. 
*  Holt,  Diseases  of  Infants  and  Children,  New  York  and   London, 
1907,  160. 


140  INFANT   FEEDING 

Peiser^  advises  the  use  of  kephir  in  the  treatment  of  am- 
bulatory cases. 

Composition  op  KIephir^ 

Nitrogenous  substances 3.49 

Casein 2.53 

Albumin 0.36 

Acid  albumin 0.21 

Hemialbumin 0.21 

Peptone 0.039 

Fat 1.44 

Lactose 2.41 

Lactic  acid 1.02 

Alcohol 0.75 

Ash 0.68 

Water 90.21 

1  Monatsschr.  f.  Kinderheilk.,  1912,  xi  (Orig.),  175. 

2  Leach,  Food  Inspection  and  Analysis,  New  York,  1913,  159. 


Fig.  9. — Utensils  necessary  for  home  modification  of  food  for  infants. 


CHAPTER  XI 

ARTIFICIAL    FEEDING    FOR    THE    NORMAL    INFANT 

GENERAL   INSTRUCTIONS 

In  preparing  food  for  the  normal  infant  certain  utensils 
are  necessary.  Most  of  these  should  be  of  graniteware, 
since  this  is  more  easily  and  thoroughly  cleansed.  A  large 
pan  for  mixing,  which  will  hold  about  2  quarts,  and  a  spoon 
for  stirring  are  absolutely  necessary.  A  funnel,  which  is 
small  enough  so  that  it  can  be  inserted  into  the  bottle, 
is  desirable.  Double-boilers  and  large  kettles  are  useful 
in  the  preparation  of  such  things  as  barley-water.  For 
the  cleansing  of  bottles  a  bottle-brush  must  be  used.  A 
glass  graduate  should  be  used  for  measuring  fluids. 

Bottles  and  Nipples. — In  choosing  a  bottle,  not  only  the 
bottle  itself  but  the  nipple  must  be  taken  into  considera- 
tion. The  chief  object  to  be  obtained  is  the  reduction  of 
the  chances  of  infection  to  a  minimum.  In  order  to  do 
this  the  rubber  of  the  nipple  should  be  the  best  possible, 
so  that  it  will  not  crack,  and  the  amount  of  rubber  surface 
coming  in  contact  with  the  food  preparation  should  be 
the  least  convenient.  In  the  opinion  of  the  writer  the 
danger  of  infecting  the  milk  lies  not  so  much  in  the  bottle 
as  in  the  nipple. 

If  the  nipple  be  cracked,  even  with  the  most  careful 
cleansing  it  becomes  impossible  to  remove  all  the  milk- 

141 


142  INFANT   FEEDING 

clots,  and  though  the  nipple  be  boiled,  these  clots  may- 
form  a  hard  coagulum  about  a  central  nidus  of  bacteria, 
which  eventually  may  be  responsible  for  infection  of  the 
food.  In  the  bottle  the  transparency  of  the  material  and 
the  smoothness  of  the  surface  renders  it  possible  to  see  and 
remove  any  such  infective  material.  For  these  reasons 
it  is  well  to  choose  a  bottle  the  shoulder  to  which  begins 
at  the  neck  and  slopes  straightly  and  directly  toward  the 
body.  This  gives  a  bottle  the  inside  of  which  can  be  readily 
cleansed  with  a  bottle-brush  and  whose  neck  is  fitted  to 
receive  the  ordinary  rubber  nursing-nipple.  The  base  of 
the  bottle  should  set  squarely  on  a  plane  smiace,  and  the 
neck  be  sufficiently  small  so  that  one  will  have  Uttle  diffi- 
culty in  adjusting  the  nipple. 

In  cleansing  the  bottle  it  should  first  be  rinsed  with  cold, 
and  then  hot  water.  The  bottle  is  then  cleansed  thoroughly 
with  soapsuds  and  the  bottle-brush,  after  which  it  is  rinsed 
and  boiled  in  water  for  five  to  twenty  minutes.  The  out- 
side is  dried  and  a  sterile  cotton-plug  closes  the  neck. 

The  nipples  are  turned  inside  out  and  a  stiff  brush  used 
for  the  mechanical  cleansing.  After  boihng,  they  are 
kept  in  a  satm^ated  solution  of  boric  acid  untU  time  for 
use. 

In  preparing  food  for  an  infant  it  is  best  to  make  up  the 
total  amount  for  twenty-four  hours.  If  water  is  to  be 
used  as  a  diluent,  it  should  first  be  steriHzed  and  then 
cooled.  Barley-water,  oatmeal-water,  etc.,  can  be  made 
up  in  sufficient  quantity  to  last  two  to  three  days  if  kept 
in  a  cool  place.  It  is  always  well  to  dissolve  the  carbohy- 
drate in  water  before  adding  the  milk.  If  this  be  starch, 
it  is  usually  necessary  to  boil  for  one-half  to  several  hours. 


Fig.  10.— Bottles  and  nipi)lrs:  rr,  The  best  .•^tyle  hoitlr  for  ^:.  n.  rul 
use;  b,  this  bottle  has  too  narrow  a  neck  and  also  a  shoulder,  which 
makes  it  difficult  to  clean;  c,  this  bottle  is  all  right,  but  the  nipple  i.s 
too  large  and  cracks  easily;  it  is  also  very  expensive;  d,  it  is  impossible 
to  clean  this  bottle  well;  e,  the  worst  type  of  bottle  and  nipple;  /,  brush 
for  cleaning  bottle. 


ARTIFICIAL   FEEDING    FOR   THE    NORMAL   INFANT     143 

If  malt-extract  is  used,  it  is  well  to  bring  to  a  boil  to  destroy 
any  enzymes  which  may  be  present.  Sugars  and  infant 
foods  can  be  dissolved  in  cold  or  only  warm  water. 

As  to  whether  the  milk  should  be  pasiteurized  or  steril- 
ized, will  depend  upon  the  source  of  the  supply  and  the 
method  of  handling,  which  in  each  case  must  be  passed 
upon  by  the  physician  in  charge.  Milk  should  never  be 
added  to  a  warm  diluent,  whether  this  be  [)lain  water  or  a 
carbohydrate  solution,  but  the  latter  should  be  cold  before 
the  milk  is  mixed  with  it. 

After  the  milk  and  diluent  are  thoroughly  mixed,  the 
prescribed  quantity  should  be  placed  in  each  sterile  bottle, 
this  sealed  with  a  sterile  cotton-plug  or  paper-cap,  and 
placed  on  ice  or  in  a  cold  place  until  ready  for  use. 

When  ready  for  use  the  nipple  is  placed  on  the  bottle, 
in  which  process  it  is  well  to  have  the  bottle  sitting  on  a 
plane  surface,  firmly  grasped  between  the  palms  of  the 
hands,  the  fingers  being  used  to  adjust  the  rubber  over  the 
neck.  The  bottle  is  then  warmed  (except  where  albumin- 
milk  is  used)  until  a  drop  of  the  fluid  on  the  back  of  the 
hand  feels  distinctly  warm  (not  hot). 

During  the  time  the  child  is  taking  the  bottle  this  should 
be  held  in  the  hand  of  the  attendant  and  adjusted  at  a 
proper  angle,  so  that  air  \\all  not  be  given  with  the  food. 
No  child  should  consume  longer  than  twenty  nor  less  than 
ten  minutes  in  taking  a  bottle.  In  many  hospitals  it  is 
the  custom  to  elevate  the  bottle  on  a  pillow  and  allow  the 
child  to  get  the  food  in  the  best  way  it  can.  This  is  cer- 
tainly to  be  deplored,  and  the  excuse  that  the  attendants  are 
too  few  should  never  be  accepted.  All  milk  left  in  the 
bottle  should  be  thrown  away. 


144  INFANT  FEEDING 

DISCUSSION  OF  STANDARDS 

For  many  yeara  past  the  so-called  percentage  method  of 
infant  feeding  has  been  advocated  in  this  country.    As  to 

just  what  is  meant  by  the  percentage  method,  it  is  rather 
hard  to  determine.  Page  upon  page  of  mathematically 
exact  formulse  have  been  pubhshed,  purporting  to  aid  one 
in  determining  a  food  suitable  for  a  given  infant.  Such 
formulse  are  not  only  unnecessary^,  but  absolutely  harmful, 
inasmuch  as  they  lead  the  average  physician  to  regard 
scientific  infant  feeding  as  a  field  too  vast  for  him  to  cover 
with  the  limited  time  at  his  disposal.  If  the  percentage 
method  means  simply  the  calculations  of  the  percentage 
of  a  certain  mixture  in  order  to  determine  the  strength  of  its 
various  constituents,  and  by  increasing  or  diminishing  one 
or  more  of  these  to  arrive  at  the  proper  food  for  the  infant 
in  question,  it  covers  so  large  a  field  that  no  one  can  deny 
its  adaptability,  though  we  may  strongly  question  the 
necessit}^  of  such  procedure.  TMiatever  the  percentage 
method,  as  advocated,  may  have  done  to  advance  the 
science  of  infant  feeding,  two  arguments  may  be  strongly 
urged  against  its  usefulness:  In  the  first  place  it  has  been 
largely  responsible  for  the  wholly  fallacious  idea  that  the 
protein  is  the  source  of  gastro-intestinal  disturbances  in 
infancy.  The  second  error,  no  less  dangerous  and  wide- 
spread in  its  results,  is  that  the  advocac}^  of  such  comphcated 
mathematic  formulse  has  driven  the  large  majority  of  the 
physicians  in  the  countr}^  to  the  indiscriminate  use  of 
patented  infant  foods.  It  seems  to  the  writer,  therefore, 
that,  if  with  no  diminution  in  scientific  principles  and  no 
increase  of  infant  morbidity,  some  method  can  be  substi- 


ARTIFICIAL    FEEDING    FOR    THE    XOUMAL    INFANT      145 

tuted  for  the  percentage  method,  it  should  be  given  pref- 
erence over  that  method. 

Heubiier  and  Rubner  have  shown  that  a  normal  breast- 
fed infant  requires  about  100  calories  of  food  to  the  kilo 
weight  (45  calorics  to  the  pound)  in  twenty-four  hours.  ^  It 
was  never  the  intention  of  these  investigators  to  give  the 
impression  that  100  calories  of  any  food-stuff  under  any 
condition  is  the  sole  requisite  in  the  proper  nutrition  of 
the  infant.  Everyone  will  readily  recognize  that  the  infant 
organism  requires  more  than  simple  fuel,  so  that  we  must 
regard  this  standard  rather  as  a  check  upon  the  amount 
of  food  than  as  any  definite  effort  to  regulate  the  nutrition 
of  the  infant  as  a  whole.  Though  this  standard  is  not 
without  exceptions,  even  in  the  normal  infant,  it  at 
least  gives  an  idea  of  the  amount  of  food  to  be  given, 
and  hence  furnishes  a  principle  in  the  nutrition  of  the 
normal  infant. 

These  two  ideas  have  been  the  dominant  ones  in  this 
field  of  medicine,  and  yet  the  ideas  conveyed  are  so  inad- 
equate for  practical  use  that  it  would  seem  necessary  to 
come  to  the  conclusion  of  Czerny,  that  each  infant  is  a  law 
unto  itself  and  must  be  treated  as  such.  It  is  doubtless 
true  that  in  the  present  state  of  our  knowledge  it  is  im- 
possible to  lay  down  exact  formulae  which  will  suffice  in 
even  the  majority  of  normal  infants.  There  may,  however, 
be  given  certain  guides  which  will  tend  to  direct  the  groi> 
ing  physician  in  the  way  he  should  go,  and  still  more  defi- 
nite ideas  of  pathologic  conditions  will  show  him  when  he  has 
passed  from  the  field  of  the  normal  into  that  of  the  abnormal. 

^  Engel  and  Samelson  (Zeitachr.  f.  I^inderheilk.,  1913,  viii,  425)  have 

recently  found  that  the  energy  quotient  for  breast-fed  children  varies 

between  100  and  120,  while  that  in  artificially  nourished  children  ia 

somewhat  lower. 
10 


146  INFANT    FEEDING 

GUIDES  TO  ARTIFICIAL  FEEDING  IN  THE  NORMAL  INFANT 

In  discussing  this  subject,  it  will  be  best  to  present  ideas 
on  nourishment  for  the  infant  from  the  third  to  the  ninth 
month,  and  then  later  to  take  up  the  more  difficult  problem 
of  the  first  three  months  of  Ufe. 

One  of  the  most  important  points  of  infant  feeding,  and 
especially  in  artificial  feeding,  is  the  length  of  the  interval 
between  nursings.  When  we  consider  that  cows'  milk  mix- 
tures do  not  leave  the  stomach  for  at  least  three  hours  after 
ingestion,  and  that  the  stomach  needs  a  rest  after  its  work, 
it  seems  very  plausible  that  a  four-hour  interval  between 
nursings  should  bring  good  results.  This  is,  in  fact,  the 
case.  It  is  never  advisable  to  feed  the  normal  infant  oftener 
than  every  four  hours.  The  best  hours  for  feeding  are 
6  and  10  a.  m.,  2  and  6  p.  m.,  and  12  midnight.  I  am 
assured  that  no  one  who  systematically  and  persistently 
tries  this  regular  four-hour  interval  during  the  day,  with 
one  feeding  at  night,  will  never  be  persuaded  to  shorten  the 
interval.  "WTien  the  infant  has  reached  the  age  of  eight  or 
nine  months,  the  midnight  feeding  may  be  given  at  10  p.  m., 
thus  allowing  the  child  an  uninterrupted  sleep  of  eight 
hours.  To  many,  the  possibility  of  such  a  thing  is  ridicu- 
lous, but  with  the  large  majority  of  babies,  nevertheless, 
this  can  be  readily  accomplished.  No  one  should  expect 
to  take  a  child  who  has  been  on  a  two-  or  three-hour  in- 
terval and  abruptly  place  it  on  a  four-hour  one  without 
some  difficulty.  This  difficulty  wiU  be  greater  the  older  the 
infant,  but  with  proper  firmness  even  a  radical  change  of 
this  sort  can,  in  the  second  or  third  month  of  life,  be  accom- 
plished with  excellent  results  within  a  week,  provided  the 
milk  mixture  is  suitable  for  the  case. 


ARTIFICIAL   FEEDING    FOR  THE   NORMAL   INFANT      147 

One  cannot  lay  too  much  stress  upon  the  advisability 
of  so  regulating  the  child's  life,  and  especially  its  nourish- 
ment, that  it  expects  certain  things  at  certain  times.  This 
not  only  systematizes  the  action  of  the  gastro-intestinal 
tract,  but  also  has  a  most  beneficial  effect  upon  the  ner- 
vous system. 

The  amount  to  he  given  at  each  feeding  must  be  determined 
largely  by  the  age  of  the  infant.  It  has  been  the  custom  of 
the  writer  to  give  slightly  more  than  the  supposed  capacity 
of  the  stomach  in  each  bottle.  One  might  expect  that  this 
would  frequently  be  accompanied  by  regurgitation,  but 
such  is  not  the  case  if  the  long  interval  is  strictly  observed. 
Undoubtedly,  a  large  amount  of  the  fluid-content  of  the 
milk  passes  the  pylorus  in  a  very  few  minutes,  which  prob- 
ably accounts  for  the  fact  that  no  distention  or  regur- 
gitation results  from  the  feeding  of  such  large  quantities. 
Therefore,  in  a  child  three  months  old,  5  ounces  would 
be  given;  in  one  six  months,  7  ounces;  in  one  nine  months, 
8  to  9  ounces.  Between  these  ages  the  amounts  can  be 
readily  calculated.  To  estimate  the  total  amount  of  food 
for  twenty-four  hours  one  simply  multiplies  the  amount  of 
each  feeding  by  5,  since  that  is  the  number  of  bottles 
given  between  the  ages  of  three  and  nine  months. 

We  come  now  to  the  determination  of  the  food  values  to 
be  given  to  the  baby  in  twenty-four  hours.  "\Miile  the 
caloric  standard  of  45  calories  of  food  to  the  pound  weight 
in  twenty-four  hours  does  not  serve  as  an  absolute  crite- 
rion, it  at  least  points  to  the  amount  which  when  exceeded 
is  likely  to  cause  difficulty.  So  we  may  say  that  though 
one  cannot  say  absolutely  that  45  calories  of  food  should  be 
given  to  the  pound  weight  in  twenty-four  hours,  he  can  at 


148  INFANT   FEEDING 

least  say  that  in  the  vast  majority  of  cases  not  more  than 
this  amount  should  be  given.  As  the  child  becomes  older 
the  food  needed  seems  to  decrease  in  amount,  so  that  from 
the  sixth  to  the  ninth  month  it  is  well  not  to  exceed  40 
calories  to  the  pound  weight. 

The  most  important  subject  is  the  composition  of  the 
food.  If  this  is  taken  up  as  to  the  amount  of  each  constit- 
uent, and  then  the  whole  correlated,  we  will  probably  best 
grasp  the  subject.  We  must  first  understand,  however, 
that  each  constituent  is  necessary  for  proper  nutrition  of 
the  infant,  and  that  it  is  the  combination  and  not  the 
single  constituent  which  brings  about  good  or  bad  results. 

Allen^  has  very  conclusively  shown  that  in  twenty-four 
hours  it  requires  the  amount  of  protein  contained  in  1  ounce 
of  milk  to  the  pound  weight  of  the  child  to  maintain  (theo- 
retically) a  nitrogen  equilibrium,  and  that  in  order  that  the 
infant  may  build  up  sufficient  nitrogen  in  his  tissues  the 
protein  of  about  1|  ounces  of  milk  to  the  pound  weight 
is  needed.  By  using  the  latter  amount  there  is,  then,  not 
only  enough  food  nitrogen  to  cover  tissue- waste,  but  enough 
also  to  supply  the  growth  of  the  organism.  I  have  found 
that  the  clinical  results  conform  very  closely  to  these  theo- 
retic calculations,  and  have  had  excellent  results  by  using 
the  amount  of  protein  advised  by  Allen.  If  we  consider  the 
protein  alone,  however,  I  am  strongly  convinced  that  much 
more  than  this  amount  can  be  given  mthout  in  any  way 
disturbing  the  infant's  nutrition,  but  I  do  not  feel  that  in  the 
normal  child  there  is  any  advantage  to  be  gained  by  so  doing. 

A  much  more  difficult  problem  to  solve  is  that  relating 
to  the  amount  of  milk-fat  to  be  used.  No  one  questions 
lArchiv.  Fed.,  1907,  xxiv,  899. 


PLATE  ill 


Normal    stool    of    child    frd   on   milk    (smi>ar  showiiiji   salve-like    coii- 

sistcncy;. 


ARTIFICIAL   FEEDING    FOR   THE    NORMAL    INFANT      149 

the  fact  that  in  nearly  all  cases  fat  cannot  be  permanently 
removed  from  the  food  without  causing  grave  disorders. 
On  the  other  hand,  such  large  quantities  of  fat  as  have  been 
used  in  the  cream  mixtures,  so  popular  in  this  country, 
have  an  effect  anything  but  beneficial  on  the  infant  organ- 
ism. If  we  are  forced  to  choose  between  no  fat  and  high  fat, 
our  choice  must  clearly  always  fall  on  the  latter,  but,  hap- 
pily, there  is  no  obstacle  to  a  middle  course  in  this  instance. 
The  energy-producing  units  in  the  food  are  to  be  found 
largely  in  the  fats  and  carbohydrates,  so  the  problem  to  be 
solved  here  is  rather  what  shall  be  the  relative  amount  of  fat 
as  compared  to  the  carbohydrates.  Any  decrease  in  fat, 
in  other  words,  must  be  supplied  by  the  carbohydrates. 
The  fat  contained  in  1^  ounces  of  whole  (4  per  cent.)  milk 
to  the  pound  weight  is  sufficient  to  cover  the  fat  need  of  the 
infant  organism,  and  in  most  cases  is  well  taken  care  of. 

It  has  usually  been  taken  for  granted  that  the  carbohy- 
drate best  suited  for  the  infant  is  milk-sugar.  There  has 
been  a  general  tendency  to  give  this  in  excess.  Of  the  three 
sugars  (milk-sugar,  cane-sugar,  and  malt-sugar),  most  babies 
will  consume  larger  amounts  of  the  malt-sugar  than  of 
either  of  the  others  without  nutritional  disorder.  Certainly 
the  normal  infant  will  receive  enough  milk-sugar,  if  this  is 
confined  in  amount  and  given  in  the  form  of  milk-sugar- 
content  of  the  amount  of  milk  required  to  supply  the  pro- 
tein and  fat.  The  rest  of  the  carbohydrate  is  best  given  in 
the  form  of  malt-sugar  and  starches,  such  as  barley,  oat- 
meal, flour-ball,  etc.  Young  infants,  even  as  early  as  the 
third  month,  will  digest  appreciable  quantities  of  starch 
perfectly,  and  later  this  constitutes  a  very  important  in- 
gredient of  the  diet. 


150  INFANT   FEEDING 

The  salts  contained  in  the  milk  are  certainly  sufficient 
in  quantity  in  the  usual  milk  mixtures.  Whether  they  are 
present  in  the  most  assimilable  form  seems  at  times  very 
doubtful.  The  attempt,  however,  to  supply  this  dejQciency 
by  the  addition  of  salts  to  the  milk  has  certainly  not  been 
successful,  so  far  as  increasing  their  absorption  and  physio- 
logic effects  is  concerned.  At  the  present  time  there  is 
no  scientific  or  practical  reason  for  the  addition  of  such  al- 
kalis as  sodium  bicarbonate  or  lime-water  to  the  food,  and 
their  use  may  be  dispensed  with  without  in  any  way  lower- 
ing the  food  value  of  the  milk  mixture. 

Summary. — If  we  now  sum  up  the  above  conclusions,  it 
is  seen  that  the  writer  beheves  in  simple  dilution  of  whole 
milk  with  the  addition  of  carbohydrates,  preferably  in  the 
form  of  malt-sugar  and  various  starches,  in  feeding  a  nor- 
mal infant  between  the  ages  of  three  and  nine  months. 
These  children  should  never  be  fed  oftener  than  every  four 
hours  during  the  day  and  once  at  night,  in  the  young  chil- 
dren the  night  bottle  being  given  at  midnight,  and  in  the 
older  ones  at  10  p.  m.  The  amount  to  be  given  at  each 
feeding  should  slightly  exceed  the  stomach  capacity  for  a 
child  of  a  given  age. 

Example. — Baby  A,  six  months  old,  weighing  14  pounds.  Stomach 
capacity  at  six  months  of  age  is  6  ounces;  therefore,  give  7  ounces  at 
each  feeding;  five  feedings  of  7  ounces  each  equals  35  ounces;  1|  ounces 
of  milk  to  the  pound  weight  are  21  oimces.  Malted  food,  1  ounce 
added. 

Final  Formula. 

Milk  (whole) 21  ounces — 441  calories 

Water 14       " 

Malt  food 1  ounce  —120       " 

Five  feedings  of  7  ounces  each 561  calories;  or, 

40  calories  per  pound. 


ARTIFICIAL   FEEDING    FOR  THE    NORMAL   INFANT      151 

Baby  B,  three  months  old,  weighing  11  pounds.  Stomach  capacity 
at  three  months  of  age  is  41  ouncey;  therefore,  give  ij  ounces  at  each 
feeding;  five  feedings  of  5  ounces  each  equal  25  ounces;  1 J  ounces  of  milk 
to  the  pound  weight  are  16J  ounces.     Malted  food,  1  ounce  added. 

Final  Formula. 

Milk 16J  ounces — 346  calories. 

Water 8i       " 

Malt  food 1    ounce  —120       " 

Five  feedings  of  5  ounces  each 466  calories;  or, 

42  calories  per  pound. 


Further  illustration  of  these  simple  principles  is  unneces- 
sary. As  to  the  amount  of  carbohydrate  to  be  added,  one 
can  only  say  that  this  will  vary  with  different  babies. 
With  the  normal  child  it  is  rarely  necessary  to  begin  with 
less  than  ^  ounce  in  twenty-four  hours.  It  is  better,  how- 
ever, to  begin  low  and  work  up  than  to  give  too  much  at 
the  beginning.  It  should  be  distinctly  understood  that  no 
set  of  formulae  yet  devised  will  suit  every  infant,  nor  is  it 
Hkely  that  such  a  degree  of  perfection  will  ever  be  reached 
when  we  consider  that  even  Nature's  efforts  in  some  cases 
are  futile,  but  from  the  above  rules  we  can  develop  formulae 
which  in  most  cases  will  bring  excellent  results.  If  the  rules 
are  to  be  follow^ed,  they  must  be  follow^ed  in  toto,  and  not 
taken  singly  and  applied.  The  interdependence  of  such 
suggestions  as  the  large  single  feeding  and  the  long  interv^al  is 
obvious.  It  will  be  seen,  too,  that  little  attention  is  paid  to 
the  dilution  of  the  milk  in  the  examples  above  given.  The 
writer  has  purposely  chosen  for  these  rather  heavy  infants. 
The  dilution  in  most  cases  would  be  greater,  though  the 
subject,  from  the  standpoint  of  clinical  result,  aside  from 
all  scientific  objection,  is  of  relatively  little  importance. 

The  foregoing  remarks  have  applied  solely  to  nourish- 
ment  between  the  ages  of  three  and  nine  months.    Be- 


152  infant:  feeding 

fore  three  months  of  age  the  artificial  feeding  of  the  infant 
is  difficult,  and  the  more  difficult  the  younger  the  infant. 
The  tolerance  for  food  other  than  breast-milk  is  smaller 
the  younger  the  infant,  thus  the  problem  is  a  difficult  one. 
Again,  it  is  extremely  hard  to  judge  of  the  effect  of  a  given 
food  at  the  time,  because  the  results  may  take  several  days 
or  even  weeks  before  manifesting  themselves.  Thus,  for 
instance,  though  a  newborn  infant  may  take  condensed 
milk  -ndthout  apparent  injurious  effect,  yet  it  may,  and 
usual!}'  does,  so  lower  the  vitaUty  that  the  shghtest  infec- 
tion may  prove  fatal,  or  after  a  few  weeks  a  marantic  state 
may  develop  from  which  it  is  almost  impossible  to  save  the 
infant.  With  such  formidable  difficulties  confronting  us, 
certainly  conser\^atism  is  demanded,  and  though  many 
infants  may  Hve  and  thrive  on  an  ample  diet,  the  physician 
who  systematically  confines  this  during  the  first  two 
weeks  of  Hfe  "^dll  meet  with  more  imiform  success. 

In  the  first  tv:enty-four  hours  the  infant  should  receive 
nothing  but  water  (sweetened  with  saccharin).^  It  is 
well  to  give  this  to  the  amount  of  1  to  2  ounces  every  four 
hours. 

During  the  remainder  of  the  first  week  it  is  best  to  give  the 
food  ever}^  four  hours  throughout  the  day  and  night,  water, 
to  the  amount  of  1  to  2  ounces  (sweetened  with  saccharin), 
being  given  between  feedings.  It  is  well  to  offer  these 
infants  3  ounces  of  a  mixture  of  half-milk  and  half-water. 
As  a  rule,  the  infant  at  firet  takes  only  \\  to  2  ounces,  but 
soon  gets  to  the  point  where  it  takes  the  whole  amount.^ 

1  Ib  the  yoTing  infant  it  is  never  necessary  to  sweeten  the  water,  but 
the  mother  or  attendant  usually  insists  on  it.     Do  not  use  sugar. 

2  Benfey  (Jahrb.  f.  Kinderheilk.,  1912,  Ixxv,  280)  has  had  excellent 
success  in  feeding  the  newborn  infant  with  albumen-milk,  and  the 
writer  can  corroborate  his  statement. 


PLATt  IV 


Xonnal  stool  of  child  fod  aiiificially  on  a  malt-sugar  mixture  (partially 

smeared). 


ARTIFICIAL   FEEDING    FOR   THE    NORMAL   INFANT      153 

At  the  beginning  of  the  second  week  a  small  amount  of 
malt-sugar  (about  a  level  teaspoonful  of  malt  food)  is  added 
to  the  twenty-four-hour  quantity  of  food ;  the  amount  is  then 
increased  from  day  to  day,  depending  upon  the  reaction  of 
the  infant.  If  it  shows  a  tendency  to  colic  and  the  for- 
mation of  gas,  the  sugar  should  be  reduced  in  quantity. 
Proceeding  in  this  careful  manner,  we  soon  arrive  at  a 
formula  with  which  the  child  is  satisfied  and  on  which  it 
gains  weight  normally. 

Between  the  second  and  the  third  month  it  is  not,  as  a 
rule,  necessary  to  change  the  dilution  of  the  milk,  but  the 
amount  given  at  each  feeding  and  the  carbohydrate  may 
be  gradually  increased.  Some  time  in  the  second  month, 
usually  when  making  the  change  from  3^  to  4  ounces  at 
each  feeding,  one  of  the  night  feedings  is  discontinued  and 
the  single  night  bottle  given  at  12  midnight.  Toward  the 
end  of  the  second  month  the  amount  at  each  feeding 
can  be  increased  to  4  or  even  4^  ounces.  One  can  usually 
at  this  time  slightly  strengthen  the  dilution  by  increasing 
the  milk  and  reducing  the  water. 

Examples 

Baby  X,  seven  days  old,  weight  8  pounds. 

Milk 9  ounces  ">„.    ,     ,.  i- r,  . 

^  .  q       »       f  Six  feedmgs  of  3  ounces  each. 

Baby  Y,  fourteen  days  old,  weight  8  pounds. 

Milk 9  ounces  1 

Water 9       "       [Six  feedings  of  3  ounces  each. 

Malt  food \  ounce    J 

Baby  Z,  two  months  old,  weight  10  pounds. 

Milk 12  ounces  1 

Water lOi     "       l-Five  feedings  of  4|  ounces  each. 

Malt  food 2  to  1  ounce  J 


154  INFANT   FEEDING 

With  the  use  of  such  a  formula,  one  can  scarcely  expect 
to  have  the  child  gain  normally  in  weight,  but  one,  in  large 
measure,  can  avoid  nutritional  disturbances  which  are  of 
such  a  grave  nature  when  they  affect  the  infant  under  three 
months  of  age. 

After  the  ninth  month,  in  sharp  contrast  to  the  early  weeks 
of  life,  it  is  no  difficult  task  to  nourish  artificially  the  normal 
infant.  The  tolerance  for  food,  both  as  to  quantity  and 
quality,  is  much  greater.  The  general  indication  is  to 
tend  to  reduce  the  amount  of  milk  and  increase  the  carbo- 
hydrates.^ At  nine  months  the  amount  to  be  given  at 
each  feeding  reaches  8  to  9  ounces ;  the  milk  (given  in  quan- 
tity according  to  weight,  1\  to  1\  ounces  to  the  pound)  is 
now  diluted  with  a  rather  thick  starch  gruel,  consisting  of 
J  to  1  ounce  of  barley  flour,  oatmeal,  or  flour-ball  to  1  pint 
of  water.  After  the  tenth  month  a  vegetable  soup  (see 
Chapter  X),  to  which  has  been  added  a  certain  amount  of 
starchy  food,  may  be  given.  This,  combined  with  milk 
and  malt-extract,  makes  a  very  palatable  mixture,  and  is 
oftentimes  of  great  value  at  this  time.  It  is  well  now  to 
discontinue  the  10  p.  m.  bottle,  thus  limiting  the  feedings 
to  four — 6  and  10  a.  m.  and  2  and  6  p.  m. 

Nourishment  During  the  Second  Year. — It  should  be  a 
rule  never  to  allow  a  child  to  drink  more  than  a  quart  of 
milk  in  twenty-four  hours.  In  many  cases  this  amount  is 
too  much,  but  in  no  case  is  it  necessary  to  give  more. 
About  this  time  or  a  Httle  later  it  is  possible  to  wean  the 
child  from  the  bottle,  but  this  maj^  be  continued  until 

^  The  relation  of  these  to  rickets  will  be  discussed  subsequently; 
at  present  suffice  it  to  say  that  this  food  is  advised  without  fear  of 
favoring  development  of  rachitis. 


ARTIFICIAL   FEEDING    FOR   THE    NORMAL    INFANT      155 

eighteen  months  or  more  if  desired.  Children  can  gradually 
be  accustomed  to  cereal  gruels  and  graham  crackers,  and 
good  arrow-root  crackers  can  be  munched  after  the  bottle. 
Fruit  juices  can  be  given  early  in  the  first  year,  but  in 
the  second  year  such  things  as  orange-juice,  prune-juice, 
or  apple-juice  should  form  a  general  article  of  diet.  After 
the  fifteenth  month  such  vegetables  as  spinach,  beets, 
and  carrots,  chopped  fine  and  pressed  through  a  colander, 
can  be  given,  and  are  usually  relished.  After  eighteen 
months,  small  portions  of  finely  divided  chicken  or  beef- 
steak can  be  added.  I  have  i)urposely  omitted  eggs  from 
this  dietary  because  in  many  cases  they  have  seemed  to  me 
to  be  distinctly  injurious.  The  diet  for  the  second  year  of 
life  consists,  in  the  beginning,  of  milk,  cereals,  and  fruit 
juices;  at  fifteen  months,  vegetables  are  added;  at  eighteen 
months,  chicken  or  rare  beef;  only  later,  if  at  all,  should 
eggs  be  given. 


CHAPTER  XII 

GENERAL    CONSIDERATION    OF    NUTRITIONAL    DIS- 
TURBANCES OF  THE  ARTIFICIALLY  FED   INFANT 

Are  the  nutritional  disturbances  of  the  artificially  fed 
infant  due  to  indigestion,  faulty  absorption,  or  disturbed 
metabolism,  or  to  all  three?  This  is  the  question  which 
confronts  the  student  of  infantile  dietetics.  There  can 
be  no  doubt  but  that  in  certain  cases  indigestion  does  play 
a  part.  By  indigestion  is  not  meant  non-digestion,  but 
disturbances  of  the  digestive  function  through  the  action 
of  the  food  or  its  derivatives.  In  most  cases,  for  instance, 
vomiting  can  be  directly  traced  to  an  irritation  of  the  gas- 
tric mucosa  by  the  food  ingested.  It  is  certain,  however, 
that  the  other  two  factors  are  of  more  general  importance 
for  the  consideration  of  our  subject.  From  the  chapter  on 
Absorption  and  Metabolism  one  will  see  that  most  foods  are 
split  up  into  absorbable  products  by  the  juices  of  the  gastro- 
intestinal canal  of  the  infant.  That  in  many  instances  these 
products  do  not  perform  their  work,  must  be  due  either  to 
a  faulty  absorption  or  a  disturbed  metabolism,  or  both. 
In  the  marantic  child,  even  though  the  food  is  sufficient  in 
quantity  to  produce  a  gain  in  weight  and  no  signs  of  indi- 
gestion are  apparent,  still  the  infant  often  fails  to  gain  and 
frequently  even  loses.  This  can  hardly  be  accounted  for 
except  by  a  deficiency  in  the  absorption  or  in  the  metabolic 
processes.      It  is  necessary,  therefore,  to  look  upon  nutri- 

156 


NUTRITIONAL   DISTURBANCES   OF   ARTIFICIAL  FEEDING     157 

tional  disturbances  not  as  disturbances  of  the  gastro-in- 
testinal  canal,  but  as  conditions  which  affect  the  whole 
organism  in  one  of  the  most  vital  of  its  functions.  The 
gastro-intcstinal  symptoms,  then,  form  only  a  part,  though 
an  important  part,  of  the  clinical  picture,  and  a  diarrhea 
becomes  only  a  symptom  and  not  a  disease.  This  broader 
conception  necessitates  the  use  of  broader  terms  and  more 
extensive  and  minute  chnical  observations,  and  makes 
possible  a  more  definite  differentiation  of  cUnical  entities. 

Diseases  in  general  are  usually  classified  in  one  of  three 
ways:  etiologically,  pathologically,  or  clinically.  In  nutri- 
tional disturbances  the  pathologic  condition  is  so  distinctly 
a  chemical  one,  and  the  anatomic  structures  are  so  little 
changed,  that  the  pathologic  method  of  classification  can 
be  left  out  of  consideration. 

The  first  systematic  attempt  to  classify  etiologically  the 
disturbances  of  nutrition  was  that  of  Czemy  and  Keller. 
They  divided  the  clinical  pictures  into  two  main  groups, 
those  occurring  from  the  food-stuffs  {ex  alimentafione) 
and  those  from  infections  (ex  infectione).  In  the  first 
group  they  include  disturbance  due  to  fat  (Milchnahrscha- 
den),  that  due  to  starch  (Mehlnahrschaden),  that  due  to 
sugar  (Zuckernahrschaden),  and  that  due  to  gelatin  (Leim- 
nahrschaden).  Of  the  last,  only  one  case  has  been  ob- 
served, and  no  further  notice  will  be  taken  of  it  than  to 
state  that  a  baby  taking  a  large  amount  of  gelatin  in  the 
food  developed,  without  any  other  distinct  s\Tnptoms, 
a  bloody  diarrhea,  which  ceased  on  the  reduction  of  the 
gelatin  in  the  food.  So  far  as  the  writer  knows,  no  similar  ob- 
servation has  been  reported.  In  the  opinion  of  Czerny 
and  Keller  the  protein  is  not  responsible  for  nutritional 


158 


INFANT   FEEDING 


disturbances  of  any  kind.    In  spite  of  the  oft-repeated 
assertion  that  the  protein  is  the  cause  of  many  of  the  nu- 


Fig.  11. — In  this  figure  the  nourishment  quantity  at  first  is  at  the 
minimum,  and  the  body  weight  remains  stationary.  Food  is  then 
taken  away  entirely,  and  then  for  some  time  remains  below  the  min- 
imum, the  body  weight  falls,  but  the  tolerance  increases.  With 
the  increase  in  food  the  weight  increases  imtil  the  maximum  is  passed, 
when  the  tolerance  is  lowered  and  there  is  a  loss  of  weight.  In  this 
figure  the  optimum  represents  the  quantity  of  food  on  which  the 
child  shows  the  best  gain,  with  no  tendency  to  intolerance,  whUe  the 
maximum  represents  the  quantity  of  food  beyond  which  one  cannot 
go  without  producing  a  nutritional  disturbance. 


tritional  disorders  encountered  in  infancy,  the  writer,  in 
his  experience,  has  never  encountered  a  case  where  any 
such  position  was  permissible,  nor  has  he  been  able  to  find 


NUTRITIONAL   DISTURBANCES   OF   ARTIFICIAL   FEEDING     159 

in  the  literature  anything  more  definite  than  assertions  that 
colic  and  constipation  were  due  to  an  excess  of  protein  in 
the  food.  He  is  well  aware  that  the  large  bean-shaped 
masses  in  the  stool  have  been  regarded  by  many  as  casein- 
curds,  and  he  is  convinced  of  the  correctness  of  this  state- 


Fig.  12. — This  figure  shows  the  effect  on  the  tolerance  of  continued 
overfeeding.  Throughout  the  food  is  above  the  maximum,  and  with 
the  continuance  of  the  nourishment  the  tolerance  is  rapidly  reduced 
until  it  is  lastingly  far  below  the  minimum,  and  death  results. 

ment.  These  curds  have  been  seen  by  him  in  stools  which 
otherwise  were  perfectly  digested,  homogeneous,  and  of 
normal  color,  so  that  he  does  not  see  how  their  presence 
can  be  interpreted  as  anything  more  severe  than  a  non- 
digestion,  a  condition  far  removed  from  indigestion.      In 


160  INFANT   FEEDING 

other  words,  he  looks  upon  these  casein  masses  as  non-irri- 


Fig.  13. — In  this  figure  we  see  the  effect  on  the  tolerance  of  too  much 
food.  If  the  same  quantity  had  been  given  over  a  longer  period,  as 
in  Fig.  12,  the  result  would  have  been  the  same,  but  in  this  case,  the 
error  being  recognized  soon  enough,  it  is  only  necessary  to  reduce 
the  food  to  the  minimima  for  a  short  time  in  order  to  increase  the 
tolerance,  and  then,  by  gradually  increasing  but  at  the  same  time 
keeping  well  below  the  maximum  (tolerance  border)  and  up  to  the 
optimum,  the  increase  of  weight  is  obtained.  One  must  remember 
that  a  given  case  at  a  given  time  has  a  certain  tolerance  for  a  certain 
food,  which  tolerance  it  cannot  exceed;  but,  on  the  other  hand,  by 
raising  the  quantity  of  that  food  above  this  maximima,  the  tolerance 
may  be  temporarily  or  permanently  lowered. 

tating  bodies,  acting  in  much  the  same  way  as  would  a 
foreign  body  of  similar  size  and  consistency.^ 
1  See  Chapter  XVU. 


NUTRITIONAL   DISTURBANCES   OF   .UITIFICIAL   FEEDING     161 

There  can  be  no  question  of  the  value  of  an  etiologic 
diagnosis.  In  fact,  to  treat  properly  a  given  condition, 
such  diagnosis  is  absolutely  necessary,  but  to  the  average 
physician  the  case  presents  a  certain  clinical  picture  which 


Fig.  14. — This  figure  shows  a  more  advanced  condition  than  that 
of  Fig.  13.  In  thi?.  in  order  to  raise  the  tolerance,  it  is  necessary  to 
reduce  the  food  far  below  the  minimum  and  then  increase  gradualhr. 

must  first  be  differentiated  from  other  clinical  pictmies, 

and  then,  if  possible,  the  cause  of  the  disturbance  must  be 

determined. 

IVIany  long  and  involved  classifications  of  the  nutritional 

disturbances  of  the  infant  have  been  attempted,  most  of 

which  have  been  so  comphcated  as  only  to  confusej  or  so 
11 


162 


INFANT    FEEDING 


indejflmte  as  to  render  it  impossible  to  distinguish  the  one 
clinical  picture  from  the  other.  The  classification  suggested 
by  Finkelstein  has  two  advantages,  it  is  simple  and  at  the 
same  time  it  covers  the  whole  field.      He  distinguishes 


^^ '  ""Fig.  15. — In  this  figure  the  food  has  remained  so  long  and  so  far 
**    /      above  the  tolerance  border  that  all  efforts  to  increase  this  by  reduc- 
,«       .\V  tion  of  the  food  fail,  and  the  child  dies,  the  tolerance  border  con- 

a3  tinuously  remaining  below  the  minimum. 

four  general  clinical  pictures:  (1)  Weight  disturbance; 
(2)  dyspepsia;  (3)  decomposition;  (4)  intoxication.  When 
one  has  learned  the  symptoms  of  each  of  these,  he  is  sur- 
prised to  find  how  readily  the  given  case  will  be  classified 
under  one  of  these  four  heads.     He  may  not  agree  with 


NUTRITIONAL   DISTURBANCES   OF   ARTIFICIAL  FEEDING     163 

Finkclstein  as  to  the  causation  of  the  clinical  picture  in 
question,  but  he  must  admit  that  his  case  can  be  readily 


re. 


'mp. 

103' 
I  OX.' 
lOO' 


Gm         Cdfor. 
XiS  /JO 


lOO     66,6 


//yectton  £x<iniAe/n. 


Fig.  16. — This  shows  very  well  the  effect  of  an  acute  general  dis- 
ease on  the  tolerance.  Many  of  the  gastro-intestinal  sjTnptoms 
given  as  a  part  of  the  clinical  picture  of  general  diseases  can  be  readily 
cured  by  simple  reductions  of  the  food.  If  during  these  acute  stages 
the  same  amount  of  food  is  given  as  during  health,  the  tolerance  is 
widely  overreached,  and  sometimes  grave  consequences  ensue.  It 
is  a  fortunate  provision  of  nature  that  under  such  circumstances  in- 
fants voluntarily  reduce  the  amount  of  the  food  which  they  will  take, 
and  this  often  contrary  to  the  wishes  of  their  attendants. 

classified  under  one  or  more  of  these  heads.     This  is  the 

general  classification  which  will  be  followed  in  this  treatise. 

Before  discussing  the  various  nutritional  disturbances, 

let  us  consider   their  general   characteristics.      This   can 


164 


INFANT   FEEDING 


best  be  done  by  following  closely  the  charts  prepared  by 
von  Pirquet.^  He  regards  as  the  chief  factor  the  tolerance 
of  the  child  for  a  given  food  at  a  given  time,  and  portrays 
the  ways  in  which  that  tolerance  can  be  reduced.  It 
is  apparent  to  all  that  if  the  food  is  insufficient  to  prevent 


Hish-  Temp, 


Fig.  17. — This  shows  graphically  the  effects  of  heat  on  the  tolerance, 
and  the  raising  of  the  tolerance  by  reducing  the  food  quantity. 

a  loss  in  weight,  the  infant  cannot  long  survive  such  treat- 
ment. If  the  tolerance  of  the  infant  for  a  given  food  be 
below  the  minimum  required  to  maintain  body  weight,  then 
that  food  must  be  replaced  by  another,  or  some  means  must 
be  found  to  otherwise  raise  the  tolerance. 


1  Zeitschr.  f.  Kinderheilk.,  1910,  i,  111. 


NUTRITIONAL   DISTURBANCES   OF   ARTIFICIAL   FEEDING     105 

Two  or  three  ideas  predominate  in  all  these  charts.     In 
the  first  place,  it  is  plainly  seen  that  if  the  food  in  any  case 


A  Coiri  ntUic  &/0%  6uffirmat 


^nutimunt' 


Fig.  18. — This  figure  is  most  instructive  in  demonstrating  the  value 
of  mothers'  milk.  We  see  showTi  here  the  difference  in  tolerance 
not  only  between  cows'  and  mothers'  milk,  but  also  between  different 
dilutions  of  cows'  milk.  If  we  remember  that  this  is  purely  schem- 
atic, we  may  prepare  for  ourselves  several  such  charts  showing  in 
dilTerent  children  the  different  tolerance  for  different  foods.  The 
tolerance  for  breast-milk  is,  almost  without  exception,  greater  than  that 
for  other  milks.  Whereas  in  a  severe  case  the  tolerance  for  cows' 
milk  may  be  well  below  the  minimum,  that  for  breast-milk  may  be  at 
or  above  this. 

is  pushed  beyond  a  certain  point  (which  must  be  deter- 
mined in  each  case,  but  which  in  the  normal  child  is  about 
40  to  50  calories  to  the  pound  weight  in  twenty-four  hours) 


166 


INFANT   FEEDING 


the  result  is  a  lowering  of  the  tolerance  for  all  foods,  but 
especially  for  that  particular  food.  In  the  next  place,  it 
is  seen  that  if  the  food  is  suflSciently  reduced  the  tolerance 
is  raised.     The  necessary  amount  of  the  reduction  depends 


Fig.  19. — This  figure  again  shows  the  greater  tolerance  for  human 
milk,  but  shows,  in  addition,  the  beneficial  effect^  which  mothers'  milk 
has  on  the  tolerance  for  other  food  in  the  newborn  infant.  This  is 
most  instructive  and  portrays  very  plainly  our  experience  that  arti- 
ficial feeding  in  the  newborn  infant  is  an  exceedingly  difficult  proposi- 
tion. 


upon  the  severity  of  the  case ;  in  the  severer  cases  the  food 
must  be  discontinued  entirely  for  a  short  period.  The 
degree  of  tolerance  regained  by  reduction  of  the  food  quan- 
tity depends  upon  the  severity  of  the  case  and  the  length  of 
time  the  disturbance  has  existed,  but  more  upon  the  latter 


NUTRITIONAL   DISTURBANCES   OF   ARTIFICIAL   FEEDING     167 

than  the  former.  And  lastly,  it  is  shown  how  the  tolerance 
for  woman's  milk  is  greater  than  that  for  any  other  food. 
The  effect  of  intercurrent  diseases  and  of  heat  in  reducing 
the  tolerance  must  agree  with  the  experience  of  all. 


Fig.  20. — This  figure  explains  why  artificial  feeding  in  the  new- 
bom  infant  is  so  difficult,  and  the  effect  of  mothers'  milk  in  produc- 
ing a  recovery. 


von  Pirquet,  in  ten  charts,  has  given  us  the  essence  of 
infant  feeding,  containing  a  bird's-eye  \dew  of  the  whole 
subject  and  the  general  indications  for  treatment.  If  one 
follows  the  more  specific  data  in  the  ensuing  pages,  he  will 
be  struck  by  the  exactness  of  these  charts. 


CHAPTER  Xin 
WEIGHT   DISTURBANCE  1 

{Synonyms. — Fat  Constipation;  MUchnahrschaden.) 

Definition. — Disturbance  of  nutrition  in  the  infant, 
caused  by  a  relatively  high  fai^content  in  the  food,  and 
clinically  characterized  by  constipation,  stationary  weight, 
increased  ammonia  output  in  the  mine,  pallor,  fretfulness, 
and  disturbed  sleep. 

Etiology. — ^The  condition  is  most  frequent  among  the 
better  classes  and  in  the  winter  months.  This  coincidence 
might  suggest  that  if  the  bacterial  content  of  the  food  is 
low  there  is  less  danger  of  decomposition,  and  as  a  result 
the  more  severe  forms  of  nutritional  disturbance  do  not 
occur.  The  same  class  of  cases  in  the  poorer  classes  and  in 
the  summer  months  usuall}^  develops  a  dyspeptic  diarrhea. 
Artificially  fed  infants  are  almost  exclusively  affected. 
Many  of  these  children  show  distinct  signs  of  exudative 
diathesis.  Whether  the  S5niiptoms  of  this  condition  are 
more  prominent  because  of  the  fat-content  of  the  food,  or 
the  condition  itself  predisposes  to  a  reduction  of  the  toler- 
ance for  fat,  is  a  question,  but  in  those  cases  where,  in  spite 
of  a  low  fat-content  in  the  food,  the  symptoms  of  exudative 
diathesis  and  weight  disturbance  appear  at  the  same  time, 
there  is  reason  to  think  that  the  cause  of  the  trouble  lies 
in  the  infant's  intolerance  for  fat,  even  in  moderate  quan- 
tities. 

1  This  conception  of  weight  disturbance  differs  materially  from  that 
of  Finkelstein. 
168 


/         WEIGHT   DISTURBANCE  1G9 

This  condition  was  first  named  "  Milchnahrschaden  " 
because  it  was  first  noticed  in  those  cases  to  which  large 
quantities  of  milk  were  given.  The  fat  is  the  constituent 
of  the  milk  at  fault.  This  does  not  mean  that  the  amount 
of  fat  in  the  food  necessarily  must  be  large,  but  that  the 
amount  of  fat  in  the  food  is  above  the  tolerance  of  the  in- 
fant for  milk-fat.  Olive  oil  and  cod-liver  oil  do  not  seem 
to  possess  the  same  degree  of  intolerance  for  most  children, 
but  even  these  may  cause  the  condition.  After  this  con- 
dition is  once  developed,  the  fat  of  woman's  milk  is  not 
so  well  borne  as  before.  Too  much  stress  cannot  be 
laid  on  the  point  that  it  is  the  relative  amount  of  fat 
and  not  the  actual  amount  which  is  to  be  taken  into  con- 
sideration. 

Pathogenesis. — The  condition  is  perhaps  produced  in 
the  following  manner:  the  fats  passing  into  the  intestinal 
canal  are  split  into  the  fatty  acids ;  to  neutralize  these  acids 
there  is  excreted  through  the  intestinal  wall  an  abnormal 
amount  of  alkalis  which,  combining  with  the  fatty  acids, 
form  insoluble  soaps.  The  withdrawal  of  the  alkalis 
from  the  system  disturbs  the  acid-alkali  equilibrium,  cre- 
ating a  relative  excess  of  acids,  or,  in  other  words,  the 
formation  of  an  acidosis,  as  evidenced  by  the  excess  of 
ammonia  in  the  urine.  The  condition,  in  contradistinction 
to  the  true  acidosis,  as  seen,  for  example,  in  diabetes  melli- 
tus,  is  known  as  relative  acidosis.  Usuki  thinks  that  this 
condition  may  be  due  to  absorption  of  too  large  an  amount 
of  fatty  acids.  According  to  Niemann, ^  a  typical  soap  stool  is 
not  necessarily  accompanied  by  increase  in  calcium  in  the  stool. 

S3miptoms. — The  infant  is  usually  presented  for  exam- 
ination because  of  two  symptoms — fretfulness  and  consti- 
1  Jahrb.  f.  Ivinderheilk.,  1912,  lxx\ii,  533. 


170  INFANT   FEEDING 

pation.  The  history  is  that  the  food  has  had  a  high  fat- 
content,  and  up  to  a  varying  period  previous  to  examiner 
tion  the  baby  has  not  only  gained  normally,  but  far  in 
excess  of  the  normal.  After  a  longer  or  shorter  period  the 
child  became  fretful,  the  stools  became  hard  and  dry,  and 
the  urine  had  a  bad  odor;  sleep  became  broken  and  rest- 
less. On  examination  you  find  a  fat,  flabby  child,  with 
pale  skin.  There  may  be  some  intertrigo  and  even  marked 
eczema. 

Gastro-intestinal  Symptoms. — Eructations  of  gas  are  quite 
common.  Vomiting  may  or  may  not  be  present,  but  rarely 
is  severe.  It  is  usually  confined  to  regurgitation  of  small 
quantities  of  milk,  which  may  or  may  not  be  curdled,  or 
else  with  the  eructation  of  gas  some  food  is  ejected.  The 
most  marked  symptom  is  the  constipation.  The  stool  is 
hard  and  dry  and  of  a  white  or  gray  color,  closely  resem- 
bling the  ordinary  dog  stool;  the  odor  is  offensive.  This 
stool,  when  perfectly  typical,  can  be  shaken  from  the  diaper 
without  leaving  a  stain  on  the  cloth.  Not  infrequently 
there  is  seen  a  small  blood-coagulum  chnging  to  the  side 
of  the  fecal  mass,  the  result  of  the  erosion  of  the  rectal 
wall  by  the  hard-formed  feces. 

This  stool  is  typical  only  of  the  fully  developed  case. 
In  the  early  stages  one  may  be  warned  of  the  approaching 
condition  by  the  appearance  of  hard,  white,  sand-like 
particles,  in  greater  or  lesser  numbers,  imbedded  in  a  fecal 
mass,  which  otherwise  is  homogeneous.  Or  later,  when  the 
condition  borders  on  a  dyspepsia,  the  stool  may  be  green- 
ish, with  some  mucus,  with  the  same  particles  usually  in 
larger  masses.  The  typical  stool  consists  largely  of  in- 
soluble soaps.  The  reaction  is  alkaline.  The  white  color 
is  the  result  of  the  changes  of  bilirubin  into  colorless  uro- 


iM   \l\i  V 


•r-v- 


.■m. 


c'^s^^ii.-' 


.^6l>^y»^  »,    '^■j.'mt^jK. 


Sidiil   shdwiiifi   ]);irli<'l('S   of   (■alcitiin  soap  ciiiIkiIcIciI    in    ?iimss  of  feces 

(soap  cunlsj. 


PI.ATH  VI 


ytyi.y:.,^.^  a.- 


Hani  falciiitii  soap  stool  of  w(>i{j;ht  (listurbanoe. 


WEIGHT   DISTURBANCE  171 

bilinogen.  The  dryness  is  due  to  the  absorption  of  water 
b}^  the  large  intestine  and  rectum  and  to  the  insoluble 
soaps.  If  this  condition  exists  for  some  time,  a  consti- 
pation very  stubborn  in  character  develops,  which  is  due 
not  only  to  the  hard  feces,  but  to  the  inertia  of  the  intes- 
tinal musculature. 

A  very  distressing  symptom  in  the  later  stages  is  the 
tendency  to  the  formation  of  gas  in  the  intestines,  with 
resulting  distention.  This  is  probably  caused  by  the  cir- 
culatory disturbance  in  the  intestines  as  a  result  of  the 
withdrawal  of  the  alkahs  from  the  intestinal  capillaries, 
and  by  the  mechanically  irritating  action  of  the  hard  fecal 
masses. 

Weight-curve. — In  many  cases  this  is  quite  characteristic. 
At  first,  when  the  child  is  fed  food  rich  in  fat,  the  gain  is 
rapid  and  marked,  perhaps  from  }  to  f  pound  a  week. 
This  condition  continues  for  perhaps  one  to  two  weeks  in 
the  typical  case.  At  the  end  of  this  time  the  weight  becomes 
stationary,  and  any  attempt  to  produce  an  increase  in 
weight  by  increasing  the  amount  of  food  either  produces 
a  dyspepsia  or  an  intoxication,  or  is  followed  by  a  decrease  in 
weight,  usually  slight  in  extent.  A  standstill  in  weight 
usually  follows  the  constipation.  In  some  cases  the  sta- 
tionary weight  is  not  preceded  by  a  previous  gain,  but  con- 
tinues with  the  constipation.  The  length  of  time  during 
which  the  weight  remains  at  a  standstill  differs  with  the 
severity  and  duration  of  the  disturbance.  If  the  con- 
stipation has  existed  for  some  time  and  has  been  of  severe 
degree,  notwithstanding  the  most  approved  and  careful 
treatment,  it  may  take  two  or  three  months  to  produce 
an  increase  in  weight,  with  cessation  of  the  other  symp- 


172  INFANT   FEEDING 

toms.     On  the  other  hand,  frequently,  a  few  days  will 
suffice  to  attain  the  desired  results. 

Skin  and  Tissue  Turgor. — These  infants  are  distinctly 
pale,  but  one  must  guard  against  judging  as  to  the  condi- 
tion of  the  skin  from  the  color  of  the  cheeks.  The  symp- 
toms of  exudative  diathesis  are  especially  frequent,  and 
as  a  consequence  the  reddened  cheek  is  often  seen.  This 
redness  is  not  the  rosy  blush  of  the  healthy  infant's  skin, 
but  the  sharply  outlined  dusky  or  bright  red  area  of  a 
beginning  eczema.  The  pallor  of  these  children  is  not  to 
be  confused  with  the  cachectic  pallor  of  the  severe  anemia 
or  the  bluish  pallor  of  the  cyanotic  marantic  infant.  It 
is  due  to  the  congestion  of  the  internal  organs,  as  a  result 
of  which  the  skin  capillaries  are  contracted.  The  pallor 
quickly  disappears  with  the  institution  of  proper  treatment 
and  the  disappearance  of  the  other  symptoms.  Eczema 
and  seborrhea  of  the  scalp  are  of  frequent  occurrence. 
Intertrigo  in  the  inguinal  folds  frequently  occurs  from 
"  scalding  "  by  the  strongly  ammoniacal  urine. 

These  children  are  frequently  fat,  but  the  tissue  turgor 
is  distinctly  reduced,  and  the  flabbiness  of  the  child  is 
often  noticed  even  by  the  mother.  The  fat  of  the  cheeks, 
as  would  be  expected,  usually  retains  its  normal  consist- 
ency.    The  peripheral  lymphs-glands  are  often  enlarged. 

Urine. — The  chief  characteristic  of  the  urine  is  the  high 
ammonia-content.  This  is  usually  detected  by  the  mother, 
who  speaks  of  the  odor  as  "  strong."  The  increased  am- 
monia is  an  indication  of  acidosis,  probably  a  relative 
acidosis,  as  mentioned  above.  The  indican  reaction  is 
usually  quite  distinct.  No  albumin  or  sugar  is  found. 
The  urine  is  highly  irritating  and  causes  excoriation  of  the 


WEIGHT   DISTURBANCE  173 

surrounding  parts.  This  increased  ammonia  in  the  urine 
is  not  readily  detected  in  the  beginning  or  light  cases, 
but  it  is  (juite  constant  in  the  more  severe. 

Temperature. — The  excursions  of  temperature  are  usually 
within  normal  limits  or,  at  most,  only  a  fraction  of  a  degree 
either  way.  Any  rise  in  temperature  marks  the  beginning 
of  a  more  severe  nutritional  disturbance  or  an  mtercurrent 
infection. 

Nervous  Symptoms. — ^These  are  usually  very  annoying. 
The  infants  are  very  peevish  and  cross,  though  apparently 
without  pain.  The  sleep  is  disturbed  and  restless,  the  child 
wakes  at  the  slightest  noise,  and  frequently  sleeps  but  a 
few  hours  in  twenty-four.  Convulsions,  etc.,  are  rather 
frequent  complications.^ 

Diagnosis. — In  the  well-developed  case  the  diagnosis, 
based  on  the  constipation,  the  history  of  the  sudden  gain 
in  weight,  which  then  becomes  stationary,  the  high  ammonia 
content  of  the  urine,  the  pallor  and  the  fretfulness,  coupled 
with  a  history  of  large  fat-content  in  the  food,  is  easy.  There 
is  no  other  condition  with  which  it  could  be  confused. 
Where  the  weight  disturbance  is  complicated  by  an  inter- 
current infection,  such  as  an  otitis  media  or  nasopharyngitis, 
the  rise  in  temperature  may  cause  one  to  think  of  an  intoxi- 
cation with  constipation.  The  general  aspect  of  the  child, 
the  absence  of  sugar  in  the  urine,  the  absence  of  deep  breath- 
ing, no  collapse,  all  speak  for  a  weight  disturbance,  even 
though  the  temperature  be  raised  several  degrees. 

The  chief  difficulty  lies  in  the  tendency  to  regard  this 
condition  as  intimately  connected  with  large  amounts  of 
fat  in  the  food.  Though  this  is  frequently  the  case,  the 
^  See  Spasmophilic  Diathesis. 


174  INFANT   FEEDING 

condition  depends  not  so  much  upon  the  quantity  of  fat 
in  the  food,  as  the  inability  of  the  infant  organism  to 
utilize  that  fat  without  suffering  from  a  nutritional  dis- 
turbance. 

Prognosis. — ^This  uncompHcated  nutritional  disturbance, 
if  properly  treated,  offers  a  very  favorable  prognosis  as  to 
life.  The  chief  danger  Hes  in  the  comphcations.  The 
duration  of  the  constipation  varies  within  wide  boundaries. 
In  one  case,  apparently  severe,  the  change  of  food  will 
produce  remarkable  results  within  a  week;  in  others,  of 
seemingly  the  same  severity,  it  will  take  months  of  the  most 
careful  attention  to  bring  the  infant  back  to  normal.  In 
the  average  case  at  least  two  to  three  weeks  pass  before  the 
constipation  is  overcome  and  the  weight  again  assumes  its 
upward  curve. 

Complications. — Among  the  common  complications  are 
the  infections  of  the  nasopharynx,  lungs,  and  middle  ear. 
One  characteristic  of  these  infants  is  their  decidedly 
lowered  resistance,  as  a  consequence  of  which  the  infections 
of  the  respiratory  tract  are  quite  common.  Another  com- 
mon complication  is  facial  eczema,  often  with  seborrhea  of 
the  scalp.  AU  these  complications  are  symptoms  of  the 
exudative  diathesis,  so  that  it  is  not  surprising  that  they 
are  so  frequently  found  in  weight  disturbance. 

Sequelae. — Weight  disturbance  is  often  the  forerunner  of 
more  serious  nutritional  disorders,  such  as  dyspepsia, 
decomposition,  and  intoxication.  A  very  common  result 
of  the  existence  of  this  severe  constipation  over  a  long  pe- 
riod is  a  failure  of  the  intestinal  musculature  to  respond  to 
ordinary  stimuli,  thereby  giving  rise  to  a  chronic  atonic  con- 
dition of  the  bowel,   which  is  very  hard  to   overcome. 


WEIGHT   DISTURBANCE  175 

Contrary  to  the  general  idea,  rickets  is  very  frequently  en- 
countered. 

Treatment. — The  general  indication  for  treatment  is 
apparent.  It  consists  in  the  reduction  of  the  amount  of 
fat  in  the  food  and  replacing  this  by  some  other  food-stuff. 
In  this  place  the  carbohydrates  offer  the  only  satisfactory 
substitute.  For  the  purpose  of  infant  feeding,  the  carbo- 
hydrates may  be  divided  into  three  groups:  (1)  Milk  and 
cane-sugar,  (2)  malt-sugar  and  preparations  containing 
malt-sugar,  and  (3)  the  starches.  In  no  case  is  it  well  to 
try  to  supply  all  the  deficiency  caused  by  removal  of  the 
fat  with  one  of  these  foods.  It  is  better,  in  general,  to  use 
all  three,  so  that  the  proportions  of  no  one  of  them  will  be 
preponderant. 

Dietetic  Treatment. — We  must  first  consider  the  fat. 
No  one  will  question  that  some  fat  in  any  food  mixture  to 
be  given  infants  is  highly  desirable.  It  is,  therefore, 
necessary  to  weigh  all  points  and  determine,  if  possible,  the 
severity  of  the  case.  In  the  most  severe  cases  it  is  useless 
to  delay  in  removing  all  fat  (as  far  as  possible)  from  the 
food;  in  other  words,  to  substitute  skimmed  milk  for  the 
whole  milk  or  cream.  When  it  is  necessary  to  do  this,  a 
trial  of  the  fat  tolerance  should,  as  soon  as  possible,  be  made 
by  substituting  1  to  2  ounces^  of  whole  milk  for  the  same 
amount  of  skimmed  milk.  If  it  is  found  that  the  infant  can 
take  care  of  this  properly,  the  fat  is  gradually  increased, 
substituting  1  or  2  ounces  of  whole  milk  for  the  same 
amount  of  skimmed  milk  every  other  day.  If  the  stools 
begin  to  show  chalky  masses  in  them  (or  even  white  sandy 

•  All  amounts  mentioned  refer  to  the  twenty-four-hour  period  and 
not  to  the  single  feeding. 


176  INFANT   FEEDING 

particles)  the  fat  should  be  again  reduced  to  the  former 
amount.  In  the  milder  cases  the  simple  reduction  in  the 
amount  of  whole  milk  and  the  addition  of  carbohydrates  is 
all  that  is  required. 

The  one  carbohydrate  which  seems  to  give  the  most  satis- 
faction in  these  cases  is  the  maltr-sugar.  In  giving  the  car- 
bohydrate, and  especially  the  sugar,  progress  should  be 
slow,  in  order  to  guard  against  a  dyspepsia.  Usually  it  is 
best  to  start  with  about  J  ounce  of  malt  extract  in  twenty- 
four  hours.  This  can  be  increased  cautiously,  1  dram  at  a 
time,  to  1  ounce  or  even  IJ  ounces,  rarely  more.  A  smaU 
amount  of  malt  food,  amounting  in  all  to  J  to  |  ounce,  is 
added  after  a  few  days  of  the  malt-extract.  Instead  of 
using  plain  water  as  a  diluent,  barley-water  is  substituted. 
In  other  words,  the  food  consists  of  about  1^  ounces  of 
skimmed  milk  to  the  pound  weight  in  twenty-four  hours, 
which  is  diluted  with  barley-water  or  oatmeal-water  to  the 
required  amount.  At  the  beginning  malt-extract  is  added, 
which  is  slowly  increased,  and  then  malt-sugar.  In  deter- 
mining whether  the  required  amount  of  malt-sugar  has 
been  added,  we  must  depend  upon  the  consistency  of  the 
stool.  Very  frequently  in  the  beginning  stages  of  the  treat- 
ment the  stool  is  not  passed  without  effort,  and  often  not 
without  help,  but  when  passed  formed,  it  should  be  of  a 
brownish  color  and  salve-like  consistency.  For  some 
reason  (possibly  because  of  the  diastase  in  it)  malt-extract 
is  much  more  active  for  overcoming  the  constipation  than 
is  malt-sugar,  so  that  though  in  the  milder  cases  a  food  con- 
taining malt-sugar  may  produce  the  wished-for  result,  in 
the  severer  cases  malt-extract  is  necessary.  It  is  frequently 
of  advantage,  when  increasing  the  fat,  to  raise  the  amount 


Fig.  21. — Method  of  insertion  of  glj^cerin  suppository. 


WEIGHT   DISTURBANCE  177 

of  the  carbohydrates  at  the  same  time.  This  tends  to  keep 
the  stool  soft  and  to  prevent  the  return  of  the  other  symp- 
toms. In  doing  this,  however,  we  must  bear  in  mind  two 
things:  The  amount  of  fat  cannot  be  thus  raised  indefi- 
nitely, for  the  tolerance  border  is  soon  reached,  and,  on 
the  other  hand,  an  excessive  increase  of  the  carbohydrates 
will  lead  to  a  state  of  dyspepsia. 

Hygienic  Treatment. — Pure,  fresh  air  is  even  more  desir- 
able in  these  infants  than  in  the  well  baby,  because  of  the 
marked  predisposition  to  respiratory  infections.  The 
skin,  too,  should  be  kept  clean,  especially  in  the  folds,  and 
the  diapers  should  be  changed  as  soon  as  they  are  wet  or 
soiled.  Great  care  should  be  taken  to  avoid  contact  with 
infectious  disease  of  any  sort. 

Medicinal  Treatment. — Any  attempt  to  overcome  a 
constipation  of  this  nature  by  the  use  of  drugs  is  to  be  con- 
demned. The  relief  of  the  constipation  is,  at  best,  tempo- 
rary, and  the  cathartic  leaves  the  bowel  more  inert  than 
before.  After  a  proper  diet  has  been  prescribed,  if  the 
bowels  do  not  move  satisfactorily,  suppositories  should  be 
introduced  at  regular  intervals,  in  order,  if  possible,  to 
stimulate  the  peristalsis  by  irritating  the  rectal  sphincter. 
I  have  never  found  a  cathartic  which  could  be  regularly 
administered  in  these  cases  without  eventually  leaving 
them  worse  than  before  its  use.  Sometimes  orange- juice 
or  the  syrup  from  stewed  prunes  will  render  excellent  ser- 
vice. 

Symptomatic  treatment  will  be  taken  up  later  in  Chap- 
ter XVII. 

12 


CHAPTER  XIV 
DYSPEPSIA 

(Synonyms. — Fatty  Diarrhea;  Zuckenahrschaden;  Duodenal  Indiges- 
tion.) 

Definition. — A  nutritional  disturbance  due  to  overfeed- 
ing by  one  or  many  of  the  food  constituents,  characterized 
by  vomiting,  diarrhea,  and  slight  elevation  of  temperature. 

Etiology. — This  condition  is  almost  as  frequent  in  breast- 
as  in  bottle-fed  babies.  In  this  place  only  the  bottle-fed 
infants  will  be  considered.  (For  Dyspepsia  in  Breast-fed 
Infants  see  Chapter  IX.) 

Dyspepsia  is  more  frequently  encountered  in  the  summer 
months  than  in  the  winter.  Thin,  delicate,  especially 
marantic  infants  are  most  susceptible,  but  no  children  can 
be  regarded  as  in  any  way  protected  against  it,  provided 
the  error  in  diet  is  sufficiently  severe.  Young  infants  under 
three  months  are  more  likely  to  be  affected,  because  at  that 
age  the  tolerance  for  food  is  rather  narrowly  limited.  In 
the  winter  months  infants  Hving  under  poor  hygienic  sur- 
roundings are  more  hkely  to  have  dyspepsia,  while  those 
existing  under  better  circumstances  are  more  inclined  to 
the  weight  disturbance;  this  is  due,  in  all  likelihood,  to  the 
tendency  among  ignorant  people  to  commit  graver  dietetic 
errors,  and  also,  perhaps  in  part,  to  contamination  of  the 
food  given  the  infant. 

The  cause  of  this  disturbance  is  overfeeding,  usually  not 

178 


DYSPEPSIA  179 

80  much  of  one  constituent,  aa  of  all  constituents,  of  the 
food.  In  older  infants  these  attacks  are  frequently  brought 
on  by  grave  errors  in  diet,  such  as  the  giving  of  cake,  bacon, 
gravy,  etc.  In  the  young  infants  the  most  frecjuent  cause 
is  an  excess  of  sugar  (either  milk,-  cane-,  or  malt-),  and  less 
often  of  fat.  One  of  the  chief  offences  in  these  young 
babies  is  too  frequent  feeding.  This  not  only  irritates  the 
stomach  and  intestines  by  keeping  them  continuously  over- 
supplied  with  work,  but  it  leads  the  mother  to  give  far 
more  food  than  the  infant  can  tolerate  because  the  single 
feeding  seems  so  small. 

There  is  some  controversy  as  to  what  constituent  of  the 
food  is  directly  to  blame  for  this  condition.  All  agree  that  in 
certain  instances  the  sugar  is  at  fault.  In  those  cases  where 
the  fat-content  of  the  food  is  high,  Finkelstein  thinks  that 
the  excess  of  fat  causes  a  lowering  of  the  tolerance  for  sugar, 
and  in  this  way  the  sugar  is  directly  at  fault.  It  is  hard 
to  explain  all  cases  in  this  way,  and  it  is  very  likely  that  a 
high  fat-content  may  be  directly  irritating  to  the  intestinal 
canal. 

Milk-sugar  and  cane-sugar  seem  to  be  most  flagrantly  to 
blame,  but  malt-sugar,  either  in  the  form  of  malt-extract 
or  malt-food,  may  cause  a  dyspepsia  which,  however,  is 
usually  of  a  mild  nature.  Among  the  prepared  foods  none 
is  more  active  than  condensed  milk,  which  is  frequently 
responsible  for  the  condition  in  young  infants,  and  pro- 
duces, as  a  rule,  a  severe  type. 

Symptoms  of  a  dyspeptic  nature  may  be  caused  by  slight 
decomposition  of  the  milk.  This  factor,  if  continued  over 
some  time,  may  cause  a  severe  disturbance,  but  if  detected 
early,  can  be  easily  remedied  by  supplying  a  good  milk. 


180  INFANT   FEEDING 

Blum^  has  reported  a  case  of  diarrhea  evidently  due  to  the 
use  of  milk  from  cows  which  had  been  fed  on  fresh  alfalfa 
hay. 

It  is  not  at  all  uncommon  for  older  infants  on  the  breast 
to  be  fed  from  the  table.  In  many  cases  this  leads  to 
attacks  of  vomiting  and  diarrhea.  The  same  may  be  said 
of  those  artificially  fed.  Attacks  of  dyspepsia  are  frequent 
complications  of  other  than  gastro-intestinal  diseases,  and 
as  such  will  be  considered  in  the  proper  place. 

Pathogenesis. — Dyspepsia  is  a  disorder  of  absorption 
and  metabolism,  and  to  some  degree  primarily  of  diges- 
tion. If  the  digestive  processes  are  involved,  it  is  usually  as 
a  result  of  the  general  condition  and  not  as  a  primary  affec- 
tion. The  formation  and  absorption  of  acids  (formed  from 
the  sugar  or  fat)  or  the  withdrawal  of  the  alkalis  from  the 
system,  caused  by  the  increased  irritation  and  consequent 
secretion  of  the  intestinal  mucosa,  may  either  or  both 
account  for  the  acidosis,  which  is  shown  by  the  increased 
ammonia  excretion  in  the  urine. 

It  has  been  shown  (Bahrdt,  Edelstein,  v.  Csonka,  Bamberg, 
Huldschinsky^)  that  the  acid  which  is  most  frequently  pre- 
sent in  large  amounts  in  the  stools  of  dyspeptic  infants  is 
acetic.  Butyric  is  present  in  amounts  of  .06  per  cent., 
while  caprillic  and  formic  acids  are  present  in  smaller  quanti- 
ties. An  increased  peristalsis  could  be  produced  by  the 
addition  of  certain  low  fatty  acids  to  the  food.  This  was 
especially  true  of  acetic  acid.  If  these  were  introduced 
through  a  duodenal  fistula,  the  increased  peristalsis  could 
be  produced  with  small  amounts  of  acid.     The  amount  of 

1  Arch.  Ped.,  1913,  xxx,  534. 

2Zeitschr.  f.  Kinderheilk.,  1911,  iii,  313,  322,  350,  366. 


DYSPEPSIA  181 

acid,  however,  which  was  rcciuircd  to  produce  these  symp- 
toms when  added  to  the  food  was  three  to  six  times  as  much 
as  can  be  formed  in  cows'  milk.  Huldschinsky^  found,  on 
examining  the  stomach  contents  from  50  infants,  that  in- 
crease in  the  volatile  fatty  acids  could  rarely  be  found.  He 
thinks  that  the  fluid  fatty  acids  of  the  stomach  can  only 
endanger  the  organism  if  the  functions  of  the  stomach  are 
already  altered.  Jundell-  finds  evidence  of  destruction  of 
body  tissue  in  dyspepsia.  The  nitrogen  retention  is  lowered 
as  is  fat  absorption,  while  the  dry  substance  of  the  feces  is 
increased.  The  excretion  of  sodium  chlorid,  calcium, 
phosphoric  acid,  and  potassium  is  increased. 

Symptoms. — ^The  essential  symptoms  of  dyspepsia  are 
vomiting  and  diarrhea,  neither  of  which  is  severe.  In 
addition,  there  is  a  distinct  tendency  to  excessive  forma- 
tion of  gas  in  the  alimentary  canal  with  resultant  dis- 
comfort. 

Gastro-intestinal  Symptoms. — ^The  vomiting  is  distinctly 
the  result  of  the  stomach  irritation.  It  maj^  come  immedi- 
ately after  feeding  or  at  any  time  between  bottles.  Vomit- 
ing may  occur  many  times,  or  once,  or  not  at  all.  The 
vomitus  is  usually  curdy  and  of  a  distinctly  acid  odor. 
Frequently  accompanying  the  vomiting  there  is  eructation 
of  gas;  this  is  a  frequent  and  very  disturbing  symptom. 

The  stools  are  passed  from  four  to  six  times  in  twenty- 
four  hours.  They  are  usually  green  and  contain  curds 
and  mucus.  In  those  cases  most  distinctly  connected 
with  excess  of  sugar  in  the  food  they  are  foamy  and  their 
passage  is  accompanied  by  much  flatus.     Where  the  cause 

1  Zeitschr.  f.  Kinderheilk.,  1913,  v,  475. 

2  Ibid.,  1913,  viii,  235. 


182  INFANT   FEEDING 

of  the  disturbance  is  an  excess  of  malt-sugar  the  stool  is 
usually  brown,  without  mucus  or  curds,  and  often  dis- 
tinctly watery  and  foamy.  The  "  curds  "  here  mentioned 
are  not  the  large,  hard,  bean-like  casein  curds,  but  small 
balls  of  mucus,  scraggly  masses  of  undigested  fat,  or  sand- 
like particles  of  insoluble  fat-soaps.  In  the  so-called 
fatty  diarrhea,  an  uncommon  affection  and  one  which 
comes  under  the  heading  of  dyspepsia,  the  stool  is  yellow 
and  oily,  and  a  portion  placed  on  a  slide  spreads  out  evenly 
in  all  directions  when  the  cover-glass  is  apphed.  Under 
the  microscope  fat-globules  cover  the  field.  Mucus  is 
found  in  the  form  of  small  balls  or  in  strings.  Blood  is 
never  present. 

Distention  of  the  abdomen  is  frequent,  due  to  disturb- 
ance of  the  intestinal  blood-supply  and  the  active  formation 
of  gas  in  the  bowel.  It  is  not  of  the  same  grave  character 
as  that  due  to  a  condition  where  the  lack  of  muscular  resist- 
ance, both  in  the  musculature  of  the  abdominal  wall  and 
in  the  intestines,  provides  little  effort  toward  the  expulsion 
of  the  gas.  In  this  condition  usually  the  abdominal  walls 
are  strong  and  peristalsis  is  active,  so  that  the  condition  is 
rather  an  active  than  a  passive  one. 

The  general  trend  of  the  temperature  is  above  the  normal, 
rarely  reaching  101°  F.  and  often  dipping  to  98°  F.  or  even 
lower.  On  studying  the  curve,  however,  it  will  be  seen 
that  the  temperature  for  the  whole  twenty-four  hours  is 
distinctly  more  above  than  below  the  normal  mean,  and 
that  the  daily  variations  exceed  by  1  or  2  degrees  those 
encountered  in  the  normal  infant. 

The  urine  contains  an  increased  amount  of  ammonia, 
but  no  albumin,  sugar,  or  casts.     Indican  may  be  increased 


PI.ATH  VII 


,/'^^^^^(S»y^ 


'•rg^ 


Infant's   stool    sliowiiif:   f;it    curds   as   scraggly   masses.     As    seen   in 

(lysjx'psia. 


DYSPEPSIA  183 

in  amount.  Though  the  ammonia-content  is  high,  as  a 
rule,  the  urine  does  not  excoriate  the  skin. 

The  shin  is  pale  and  the  tissue  turgor  is  distinctly  reduced. 
Oftentimes  the  highly  acid  stools  excoriate  the  skin  about 
the  anus.  Very  often  an  existent  moist  facial  eczema  will 
be  manifestly  improved  by  an  attack  of  dyspepsia. 

During  the  first  days  of  this  condition  there  is  a  distinct 
though  usually  not  marked  loss  in  weight.  This  may 
amount  to  as  much  as  ^  pound  in  forty-eight  to  seventy-two 
hours.  After  that  the  weight  remains  stationary  or  only 
gradually  diminishes.  Daily  variations  may  be  quite 
marked,  but  as  long  as  the  dyspeptic  condition  continues 
the  general  trend  of  the  weight-curve  is  downward. 

The  infants  are  not  only  restless  and  nervous,  but  suffer 
from  distinct  pain,  due  to  the  accumulation  of  gas  in  the 
intestinal  canal.  The  attacks  of  pain  are  similar  to  those 
found  in  the  breast-fed  child  under  similar  conditions. 
Sleep  is  broken  and  restless.  WTien  awake  the  infant,  if 
not  crying  and  peevish,  is  never  still,  but  is  boring  the 
head  into  the  bed,  drawing  up  its  legs,  rolling  the  eyes, 
and  perhaps  gnawing  its  fingers. 

Diagnosis. — In  the  diagnosis  of  this  condition  at  times 
peculiar  difficulties  present  themselves.  In  the  first  place 
we  must  distinguish  dyspepsia  from  parenteral  affections, 
and  in  the  next  place  the  different  causative  factors  must 
be  differentiated. 

In  general,  a  parenteral  disease  which  resembles  dyspep- 
sia or  (perhaps  it  would  be  better  to  say)  causes  dyspep- 
tic symptoms,  differs  from  this  in  two  main  points:  The 
temperature  is  either  elevated  or  normal,  and  not  the  low 
fever  of  the  dyspepsia,  and  the  nervous  system  is  differ- 
ently affected. 


184  INFANT   FEEDING 

Not  infrequently  congenital  syphilis  is  accompanied  by 
vomiting  and  the  increase  of  the  number  of  stools  to  four  to 
six  a  day,  green,  and  containing  curds  and  mucus.  But  in 
congenital  syphilis  the  temperature  is  almost  invariably 
normal  or  subnormal,  the  spleen  is  enlarged,  there  are 
eruptions  of  various  kinds  on  the  body,  and  the  child, 
though  cross,  is  not  alert  and  active.  The  Wassermann  re- 
action and  especially  the  therapeutic  test  are  of  great  value. 

In  miliary  tuberculosis  the  only  symptom  which  attracts 
the  mother  is  often  the  diarrhea,  but  in  this  disease  the 
temperature,  though  irregular,  is  well  above  normal;  here, 
too,  a  spleen  is  to  be  palpated,  a  cough  is  often  present,  and 
the  infant  is  much  more  likely  to  be  apathetic  than  cross 
and  irritable. 

Another  condition  which  often  shows  dyspeptic  symp- 
toms is  otitis  media.  In  this  condition  the  temperature 
is,  as  a  rule,  out  of  aU  proportion  to  the  dyspeptic  symp- 
toms. Usually  the  simple  expedient  of  pressing  the  finger 
over  the  external  auditory  meatus  T\dU  give  a  good  idea  of 
the  seat  of  pain,  which  can  be  confirmed  by  examination 
of  the  tympanic  membrane. 

A  nasopharyngitis  may  prove  Yery  puzzHng,  because  one 
will  not  know  whether  he  has  a  case  of  nasopharyngitis 
with  dyspeptic  symptoms  or  dyspepsia  complicated  by  a 
nasopharyngitis.  From  a  practical  standpoint  it  is  much 
more  profitable  to  pay  attention  to  the  dietetic  treatment 
than  to  the  local  treatment,  so  that  it  is  not  of  paramount 
importance  to  distinguish  between  the  two  possibiUties. 

Of  course,  dyspeptic  symptoms  may  occur  in  many  other 
conditions,  such  as  bronchopneumonia,  etc.  The  discus- 
sion of  these  will  be  deferred  to  a  later  chapter. 


DYSPEPSIA  185 

The  only  nutritional  disturbance  with  which  it  is  at  all 
likely  that  dyspci^sia  will  be  confused  is  intoxication.  Tlie 
difference  is  largely  one  of  degree.  The  serious  condition 
of  the  patient,  the  high  temperature,  the  deep,  pauseless 
breathing,  the  semicomatose  state,  the  albuminuria  and 
the  lactosuria,  and  the  leukocytosis,  all  speak  for  an  intoxi- 
cation. As  a  rule,  too,  the  number  of  stools  in  intoxication 
is  much  greater  than  in  dyspepsia.  An  enlargement  of 
the  liver  in  a  fat  baby  suggests  intoxication  rather  than 
dyspepsia. 

After  the  diagnosis  of  dyspepsia  is  made,  it  becomes 
necessary  to  distinguish  the  cause  of  the  dyspepsia.  There 
are  two  distinct  causes — the  sugar  and  the  fat.  In  the 
cases  of  dyspepsia  due  to  overfeeding  with  sugar  the  pre- 
dominant symptom  is  the  formation  of  gas;  this  manifests 
itself  in  four  ways:  eructations,  distention,  coHc,  and  foamy 
stools. 

Where  malt-sugar  is  to  blame,  the  stool  is  usually  brown- 
ish, while  in  those  cases  where  the  milk-  or  cane-sugar 
has  caused  the  dyspepsia,  the  stools  are  usually  grass- 
green  and  contain  mucus  and  fine  curds. 

Whereas  the  weight  disturbance  occurs  often  with  small 
amounts  of  fat  in  the  food,  dyspepsia,  if  due  to  fat  at  all, 
can  usually  be  traced  to  cream  mixtures.  The  symptoms  are 
not  greatly  different  from  those  of  sugar  dyspepsia,  except 
that  gas  formation  is  not  so  prominent  a  symptom.  The 
stool  may  be  that  of  a  fatty  diarrhea,  i.  e.,  oily  and  composed 
almost  entirely  of  fat-globules,  or  it  may  be  green  and  con- 
tain the  chalky  curds  of  the  insoluble  soaps.  A  history 
of  preceding  fat  constipation  is  not  infrequent. 

The  cases  of  dyspepsia  due  to  decomposition  of  the  food 


186  INFANT   FEEDING 

are  not  common,  because  it  is  rare  that  an  infant  would  be 
given  milk  sour  enough  to  cause  this  disturbance.  The 
only  method  of  making  the  diagnosis  is  by  the  history.  In 
fact,  there  is  some  question  whether  acid  decomposition  in 
milk  is  ever  sufficient  in  itself  to  produce  dyspeptic  symp- 
toms. 

Prognosis. — Dyspepsia  in  itself  is  not  a  fatal  condition, 
but  in  the  first  three  months  of  Hfe  it  very  often  is  the 
beginning  of  a  state  of  decomposition  (marasmus)  which 
is  very  baffling  from  a  therapeutic  standpoint.  If  dyspep- 
sia occurs  in  a  bad  case  of  decomposition  the  outlook  is  very 
serious. 

Dyspepsia  under  proper  treatment  ceases  within  twenty- 
four  to  forty-eight  hours,  but  if  not  properly  cared  for, 
continues,  and  finally  ends  in  a  decomposition,  intoxication, 
or  an  intercurrent  infection. 

Complications. — The  comphcations  are  not  many.  Naso- 
pharyngeal infections  often  follow  attacks  of  dyspepsia, 
and  are  probably  the  result  of  the  lowering  of  the  resist- 
ance. Excoriation  of  the  skin  about  the  buttocks  by  the 
irritation  of  the  stool  is  sometimes  seen.  In  other  diseases, 
such  as  pneumonia,  dyspepsia  is  more  often  secondary 
than  primary. 

Sequelae. — The  sequelae  are  of  much  more  importance 
than  the  comphcations.  The  decomposition  which  so 
frequently  follows  a  sugar  dyspepsia  of  the  early  months 
of  life  is  a  most  severe  condition,  and  one  which  requires 
the  greatest  resourcefulness  to  combat.  Intoxication  is 
another  frequent  sequela  of  dyspepsia.  This  is  often  an 
especially  severe  form  because  of  the  previous  depleted 
state  of  the  infant  due  to  the  dyspepsia. 


DYSPEPSIA  187 

Treatment. — ^The  dietetic  treatment  consists  essentially 
in  reduction  of  the  food.  In  the  severest  or  most  prolonged 
cases  it  is  best  to  give  barley-water  sweetened  with  sac- 
charin (not  sugar)  for  twenty-four  hours.  Then  follow 
with  a  skimmed  milk  and  water  mixture,  starting  with 
about  1  ounce  of  skimmed  milk  to  the  pound  weight  in 
twenty-four  hours.  The  skimmed  milk  is  increased  at 
the  rate  of  1  to  2  ounces  a  day  until  the  infant  is  getting 
about  1^  ounces  of  skimmed  milk  to  the  pound  weight  in 
twenty-four  hours.  The  skimmed  milk  is  then  gradually 
replaced,  1  or  2  ounces  at  a  time,  with  whole  milk,  and  malt- 
extract  is  cautiously  added  to  prevent  fat  constipation. 
In  the  less  severe  cases  the  general  Hne  of  treatment  is  the 
same,  except  that  the  progress  is  more  rapid.  The  infant 
at  the  beginning  of  the  treatment  may  be  given  an  amount 
of  skimmed  milk  equal  to  1|  ounces  to  the  pound  weight 
in  twenty-four  hours,  or  this  initial  food  may  be  a  whole 
milk  mixture  in  the  dilution  of  1  to  3. 

In  the  young  infants  under  three  months  of  age  the  al- 
bumin-milk, if  properly  given,  is  most  satisfactory.  No 
one  should  try  to  give  this  food  unless  he  has  had  sufficient 
experience  with  it  to  be  able  to  get  a  fairly  stable  mixture. 
I  am  persuaded  that  failures  are  due  largely  to  the  inability 
of  those  using  this  food  to  prepare  it.  In  dyspepsia,  at  the 
beginning  of  treatment  or  just  after  the  twenty-four-hour 
starvation  period,  the  food  should  be  given  to  the  amount 
of  3  ounces  to  the  pound  weight  in  twenty-four  hours. 
Within  a  few  days  malt  food  or  malt-extract  should  be 
added  gradually,  beginning  with  about  \  ounce  in  twenty- 
four  hours  and  increasing  to  1  ounce  or,  at  most,  Ih  ounces. 
One   should   be   cautious  about  giving  this  food  in  full 


188  INFANT   FEEDING 

amount  or  in  adding  the  carbohydrates.  A  careful  mother 
can  soon  learn  to  prepare  it;  and,  of  course,  such  modificsr 
tions  as  the  substitution  of  skimmed  milk  for  buttermilk  can 
be  used,  though  they  are  probably  not  so  efficacious. 

One  must  be  careful  in  these  cases  of  dyspepsia  in  giving 
either  milk-  or  cane-sugar,  since  a  small  amount  of  either 
may  be  very  troublesome.  Even  though  the  dyspepsia 
be  apparently  of  the  type  due  to  overfeeding  of  fat,  the 
sugar  must  be  reduced. 

Breast-milk  is  of  especial  advantage  in  those  children 
under  three  months  of  age.  It  should  never  be  given  ex- 
cept after  a  star^^ation  period  of  twenty-four  hours,  when 
the  dyspeptic  sj^mptoms  have  disappeared.  The  nursing 
period  should  at  first  be  limited  to  three  to  five  minutes, 
and  then  gradually  increased.  These  infants  should  never 
be  nursed  oftener  than  everj'  four  hours. 

"\Mien  dyspepsia  complicates  decomposition,  one  must 
be  verA'  careful  not  to  prolong  the  starvation  period.  It  is 
often  of  advantage  not  to  take  away  food  entirely,  but  to 
begin  with  smaU  amounts  and  work  up  slowly.  This  com- 
bination is  especially  severe  and  one  offering  many  difficul- 
ties in  treatment. 

It  is  very  important  that  the  hygienic  treatment  be 
taken  care  of.  The  daily  bath  should,  of  course,  be  given,  and 
the  diaper  should  be  changed  immediately  after  urination, 
but  especially  after  defecation.  Fresh  air  is  very  important, 
and  the  company  of  individuals  having  infections  of  the 
respirator}^  tract,  even  though  slight,  should  be  avoided. 

In  uncompHcated  dyspepsia  there  is  no  indication  for 
medicinal  treatment.  The  use  of  an  initial  cathartic  is 
not  necessary.     If  the  vomiting  becomes  severe,  stomach- 


DYSPEPSIA  189 

washing,  with  the  administration  of  a  bismuth  mixture, 
may  cause  relief.  The  symptoms  are,  however,  the  direct 
result  of  poor  feeding,  and  the  correction  of  the  diet  is  the 
all-important  thing  in  the  treatment.  Clock^  and  Sinclair^ 
have  reported  excellent  results,  however,  by  the  use  of  lac- 
tic acid  bacillus  cultures,  and  I  am  able  to  confirm  these 
results,  but  I  do  not  think  the  extreme  claims  of  Clock  are 
justified.  Aschenheim^  uses  calcium  lactate  in  these  cases 
as  an  adjuvant  to  treatment  in  order,  if  possible,  to  produce 
soap  stools. 

1  Jour.  Amer.  Med.  Assoc,  1913,  Ixi,  164. 

2  Arch.  Ped.,  1913,  xxx,  529. 

»  Monatsschr.  f.  Kinderheilk.,  1913,  xii  (Orig.),  229. 


CHAPTER  XV 

DECOMPOSITION 

{Synonyms. — Marasmus;  Atrophy;  Malnutrition.) 

Definition. — A  chronic  state  of  malnutrition  seen  in  in- 
fants, characterized  by  inabiHty  so  to  assimilate  the  food 
given  as  to  gain  weight  properly;  by  subnormal  tempera- 
ture, by  emaciation,  and  by  a  greatly  lowered  resistance. 

Etiology. — ^To  approach  this  subject  in  the  proper  way  it 
is  necessary  to  distinguish  cases  of  this  sort  dependent 
on  nutritional  disturbances  from  those  due  to  parenteral 
affections.  The  latter  will  be  taken  up  in  succeeding 
chapters;  in  this  we  will  deal  only  with  decomposition  or 
marasmus  due  to  nutritional  disorders. 

The  gastro-intestinal  disturbances  which  cause  decompo- 
sition almost  always  begin  before  the  third  month.  The 
earlier  in  life  these  disturbances  occur,  the  more  likely  are 
they  to  lead  to  a  chronic  state  of  malnutrition.  As  a  rule, 
this  condition  is  dependent  not  upon  a  single  attack  of 
dyspepsia,  but  upon  repetition  of  these  attacks.  The  pre- 
ceding disturbances  may  be  dyspepsias  or  intoxications, 
or  perhaps  both;  the  weight  disturbance  rarely  is  followed 
by  a  decomposition  unless  it  is  extremely  severe,  or  is  of 
that  peculiar  type  designated  by  Czerny  Mehlnahrschaden 
(starch  nutritional  disturbance). 

A  high  sugar-content  of  the  food  seems  to  be  the  most 
frequent  history  in  these  cases.     In  fact,  in  a  large  propor- 

190 


DECOMPOSITION  191 

tion  the  infant  has  been  fed  during  the  early  months  of 
life  on  condensed  milk.  The  tendency  to  decomposition 
does  not  seem  to  be  so  great  where  a  reasonable  amount 
of  fat  has  been  given. 

In  older  children  gross  errors  in  diet,  continued  over 
some  time,  with  repeated  attacks  of  dyspepsia  or  intoxica- 
tion, are  usually  responsible.  Sometimes,  however,  an 
ill-managed  single  attack  of  intoxication  may  be  followed 
by  a  long  period  of  marasmus. 

Decomposition  is  seen  in  its  most  advanced  forms  almost 
only  in  the  poorer  families  and  in  orphan  asylums;  the 
milder  degrees,  however,  are  very  frequently  seen  in  more 
prosperous  homes.  Rickets  can  hardly  be  regarded  as  a 
contributing  factor,  for  these  children  rarely  show  even  a 
moderate  form  of  this  disorder.  Poor  hygienic  surround- 
ings, with  foul  air  and  improper  care,  probably  contribute 
in  large  measure  to  the  development  of  the  chronic  state 
of  malnutrition.  Decomposition  is  most  often  seen  in  the 
winter  months,  not,  in  all  likelihood,  because  of  any  direct 
influence  of  cold  weather,  but  because  in  the  summer 
months  similar  cases  die  from  acute  disturbances. 

Pathology. — Anatomic  changes  are  veiy  few  and  not  well 
marked.  In  the  intestines  Helmholz^  has  noted  the  pres- 
ence of  superficial  duodenal  ulcers,  but  as  yet  this  finding 
has  not  been  widely  confirmed.  The  same  investigator 
thinks^  that  the  intestinal  mucosa  is  less  resistant  to  post- 
rnortem  digestion.  He  found  no  special  changes  in  Paneth's 
cells.  Schelble,^  after  exhaustive  examinations,  records 
the  "  complete  absence  of  organic  changes  in  the  digestive 

»  Arch.  Pod.,  Ifl09,  xxvi,  6S1. 

*  Jahrb.  f.  Kinderhoilk.,  1000,  Ixx,  4.5S. 

'  Studien  bei  Emahrungstorungen,  Leipzig,  1010. 


192  INFANT   FEEDING 

organs  recognizable  with  our  present  methods."  Nor 
could  that  investigator,  on  bacteriologic  examination, 
find  any  evidence  of  a  bacterial  cause  of  the  condition. 
In  the  hver  and  spleen  Helmholz  was  able  to  demonstrate 
an  increase  of  iron-pigment.  The  amount  of  pigment 
bore  no  relation  to  the  severity  of  the  case,  but  there  did 
exist  a  certain  interrelation  between  the  amount  of  pigment 
in  the  hver  and  that  in  the  spleen.  When  the  hver  con- 
tained httle  or  no  pigment,  the  spleen  contained  large 
amounts,  and  vice  versa.  This  increased  pigment,  however, 
was  not  demonstrated  by  Schelble. 

Pathogenesis. — ^The  most  exhaustive  work  on  the  metabo- 
hsm  of  decomposition  has  been  carried  out  by  Courtney.^ 
She  found  no  disturbance  of  protein  metabohsm,  but  the 
fat  absorption  was  appreciably  and  at  times  markedly 
diminished  as  a  result  of  increased  peristalsis  and  a  high 
content  of  insoluble  soap  in  the  feces.  The  formation  of 
fatty  acids,  however,  did  not  reach  such  a  degree  that  the 
ash-content  of  the  intestinal  tract  was  insufficient  to  neu- 
tralize them.  There  was  no  distinct  tendency  to  acidosis. 
Frank  and  Wolffs  and  Schlossmann  show  that  the  respi- 
ratory quotient  corresponds  to  the  body  surface  and  not 
to  the  body  weight. 

These  findings  would  seem  to  point  to  a  deficiency  on  the 
part  of  the  organism  to  assimilate  and  use  or  store  up  the 
heat-  and  energy-producing  portions  of  the  food,  and  thus 
conserve  the  body  energy.  The  power  of  assimilation  of 
olive  on  seemed  to  be  in  some  cases  much  greater  than  that 

1  Amer.  Joiir.  of  Diseases  of  Child.,  1911,  i,  321. 

2  Jahrb.  f.  Kinderheilk.,  1913,  Ixxviii,  Erganzungsheft  1. 

3  Zeitschr.  f.  Kinderheilk.,  1912,  v,  227. 


DECOMPOSITION  193 

for  milk-fat.  Interesting  in  regard  to  absorption  are  the 
investigations  in  osmosis  by  Mayerhofer  and  Pribram.' 
They  found  that  while  osmosis  through  the  intestinal  wall 
of  infants  dead  of  acute  gastro-intestinal  disease  was  more 
rapid  than  normal,  the  osmosis  through  that  of  an  infant 
dead  of  chronic  nutritional  disturbance  was  much  slower. 

It  is  very  likely  that  there  is  in  decomposition  a  lowered 
absorption  by  the  intestinal  mucosa,  which,  however,  is 
purely  chemical  in  nature,  and  does  not  manifest  any  ana- 
tomic changes  which  can  account  for  the  degree  of  impair- 
ment of  function.  In  addition,  there  may  be  a  marked 
disorder  of  internal  metabolism,  which  makes  it  impossible 
for  the  organism  to  utilize  even  those  products  which  are 
absorbed.  Upon  the  degree  of  impairment  of  these  two 
functions  depends  the  severity  of  the  case.  In  those  cases 
of  decomposition  due  to  starch  over-feeding,  Hayashi^  found 
that  in  5  out  of  8  cases  the  fat  had  altogether  disappeared 
from  the  liver.  In  1  of  the  others  the  fat  was  very  much 
reduced  and  in  1  there  was  some  fatty  degeneration.  Stolte,^ 
on  examination  of  the  liver  in  these  cases,  found  that  the  dry 
substance  was  reduced  and  the  total  ash  was  increased. 
Nitrogen,  fat,  magnesium  sulphate,  and  phosphorus  were 
practically  unchanged.  Stolte  thinks  that  in  this  condition 
the  organism  is  rich  in  water. 

Symptoms. — In  general,  these  cases  are  marked  by  their 
lack  of  symptoms  rather  than  by  anj-  pronounced  group  of 
clinical  manifestations.  Common  to  all  is  the  emaciation, 
the  degree  of  which,  as  a  rule,  depends  upon  the  duration  of 

1  Wicn.  klin.  Wochenschr.,  1909,  xxii,  875. 

2  Monatsschr.  f.  Kinderheilk.,  1913,  xii  (Orig.),  221. 
» Jahrb.  f.  liinderheilk.,  1913,  Ixxviii,  167. 

13 


194  INFANT  FEEDING 

the  condition.  Some  are  quite  irritable,  while  othei^  are 
content  to  He  all  day  without  any  apparent  discomfort  or 
distress,  all  are  hungry  and  eager  for  food,  which  cannot  be 
given  in  quantities  sufficiently  large  to  satisfy  the  apparent 
demand  without  endangering  life,  "^^omiting  may  or  may 
not  be  present,  and  there  is  a  tendency  rather  to  constipa- 
tion than  to  diarrhea.  The  temperature  is  regularly  sub- 
normal, oft«n  markedly  so.  In  the  severest  case  the  child 
looks  like  a  diminutive  wrinkled  old  man.  Pacchioni^ 
thinks  that  there  is  also  a  deficient  functional  activity  of 
the  cells  which  is  hereditary  in  character. 

Skin  and  Tissue  Turgor. — The  skin  is  pale,  often  a  trans- 
parent white.  Sometimes  in  advanced  cases  it  takes  on  a 
brownish  hue.  This  latter  is  more  frequent  in  cases  of  de- 
composition due  to  exclusive  starch  diet  (Mehlnahrschaden). 
In  the  severest  cases  and  just  before  death,  cyanosis  gives  a 
grayish  hue  to  the  skin;  this  tint  is  first  noticed  about  the 
mouth,  but  is  usually  universal.  Not  infrequently  a  dry 
scaling  eczema  is  encountered.  This  usually  occurs  on  the 
thorax  or  face,  and  is  very  chronic  in  its  nature.  The 
moist  forms  of  eczema  are  never  seen. 

The  subcutaneous  fat  is  practically  absent  over  the  entire 
body,  except  in  the  milder  cases  in  the  cheeks.  In  many 
extremely  emaciated  infants  there  stiU  remains  a  small 
pad  of  fat  in  each  cheek,  although  the  skin  over  the  rest  of 
the  body  is  in  folds  and  shows  no  signs  of  subcutaneous 
fat.     (See  Chapter  III.) 

Temperature. — ^Characteristic  of  this  condition  is  a  sub- 
normal temperature.  By  this  is  meant  not  that  at  all 
times  the  temperature  is  below  the  lower  hmits  of  the 

1  La  Pediatria,  1913,  xxi,  728. 


Fig.  22. — Case  of  deconiixjsilion. 


Fig.  23. — Case  of  decomposition. 


DECOMPOSITION 


195 


normal,  but  that  an  aggregate  of  the  day's  temperature, 
taken  at  frequent  intervals,  will  be  below  the  normal  taken 
under  the  same  conditions.  In  the  severest  cases  and  es- 
pecially during  a  collapse  the  temperature  (rectal)  may  go 
as  low  as  95°  F.  or  even  lower,  and  in  the  moderate  forms 
of  the  condition  it  is  not  unusual  for  the  morning  reading  to 


Dec.  25 


Dec.  26  Dec.  27  Dec.  28 


Fig.  24. — The  temperature-curve  of  a  case  of  decomposition,  showing 
the  acute  fall  during  a  collapse. 

be  97°  F.  for  days  at  a  time.  A  registration  of  over  99°  F. 
is  rare,  unless  caused  by  some  complication.  Though  the 
bettering  of  the  condition  is  usually  accompanied  by  a  grad- 
ual return  to  normal  temperature,  the  opposite  is  rarely 
true.  A  lowering  of  the  temperature  is  not.  as  a  rule,  grad- 
ual, but  results  from  a  sudden  collapse,  with  an  accompany- 


196  INFANT   FEEDING 

ing  drop  of  often  2  or  3  degrees  in  a  very  few  minutes 
(Fig.  24).  After  the  collapse,  if  the  child  survives,  it  may- 
take  several  days  for  the  temperature-curve  to  return  to 
its  former  height. 

Weight. — Quite  characteristic  of  these  cases  is  a  station- 
ary or  steadily  falling  weight.  In  the  milder  cases  the  weight 
remains  at  the  same  level,  perhaps  showing  daily  variations 
of  1  or  2  ounces  for  weeks  at  a  time,  in  spite  of  the  most 
careful  dosage  of  the  food.  In  the  severest  cases  the  child 
loses  weight  steadily  up  to  the  time  of  death. 

The  great  problem  is  to  give  enough  food  so  that  the 
weight  is  maintained,  and  at  the  same  time  not  so  much  as 
to  cause  gastro-intestinal  disturbance.  If  the  food  is  in- 
creased in  quantity  past  the  point  of  tolerance,  these  in- 
fants will  react  with  a  fall  in  weight  frequently  not  accom- 
panied by  any  gastro-intestinal  symptoms  whatever. 
This  reaction  (the  more  food  the  less  weight)  is  called  by 
Finkelstein  the  paradoxic  reaction,  and  is  of  great  import- 
ance in  determining  the  tolerance  of  the  child  for  the  par- 
ticular food  mixture  given.  In  the  most  severe  cases  the 
border  of  tolerance  is  below  that  for  the  amount  of  food 
necessary  to  sustain  life.  Hence  the  inevitable  result  must 
be  death,  since  if  we  keep  within  the  boundaries  of  tolerance 
the  infant  must  starve;  if  we  exceed  this  amount,  a  nu- 
tritional disturbance  develops  which  ends  fatally.  It  is 
hardly  necessary  to  state  that  here  as  elsewhere  the  toler- 
ance for  different  foods  is  different,  so  that  whereas  an  in- 
fant might  not  be  able  to  tolerate  even  minimal  quantities 
of  a  whole  milk  mixture,  on  the  other  hand,  its  tolerance  for 
breast-milk  might  be  well  above  that  amount  necessary 
simply  to  sustain  life. 


DECOMPOSITION  197 

During  a  collapse  the  loss  of  weight  is  out  of  all  pro- 
portion to  the  general  symptoms,  which  can  only  be  ex- 
plained by  assuming  that  some  sudden  factor  has  brought 
about  a  dissolution  of  the  chemical  combinations  in  which 
part  of  the  tissues  is  held  (most  probably  the  water  and 
salts),  and  that  as  a  result  these  are  excreted  (the  water 
through  the  lungs,  kidneys,  and  skin,  and  the  salts  through 
the  kidneys  and,  possibly,  the  intestinal  wall).  The  loss  of 
weight  during  a  period  of  collapse  may  attain  8  to  10  ounces 
in  a  very  short  time. 

After  a  longer  or  shorter  period  of  reparation  the  infant 
begins  to  increase  in  weight.  This  not  infrequently  occurs, 
even  though  the  food  mixture  has  remained  weeks  without 
change  in  amount  or  composition.  If  during  this  stage  of 
convalescence  no  attempt  is  made  to  hurr}^  recovery  by 
increasing  the  food  too  rapidly,  and  hence  no  nutritional 
disturbance  intervenes,  it  is  not  unusual  to  see  a  steady 
gain  of  8  to  10  ounces  a  week,  continued  for  many  weeks. 
The  stage  of  reparation  is  much  shorter  in  the  older  than  in 
the  younger  infants,  and  the  final  results  in  both  are  fre- 
quently surprising. 

Gastro-intestinal  Symptoms. — Symptoms  referring  to  the 
gastro-intestinal  tract  are,  as  a  rule,  few  and  unimportant. 
Hunger  is  a  prominent  symptom,  and  is  manifested  by 
gnawing  the  fingers  and  hands,  and  by  the  frantic  eagerness 
with  which  these  infants  take  the  bottle.  Occasionally 
an  increased  flow  of  saliva  with  drooling  is  noticed.  Eruc- 
tation of  gas  is  not  commonly  seen,  nor  is  vomiting,  though 
at  times  regurgitation  of  food  may  prove  troublesome. 
Abdominal  distention  is  infrequently  present.  In  the  milder 
cases  a  slight  atonic  constipation  is  the  rule,  while  in  the 


198  INFANT   FEEDING 

severer  ones  a  slight  diarrhea  (five  to  six  greenish  mucous 
and  curdy  stools  in  twenty-four  hours)  is  often  seen. 

Prolapse  of  the  rectum  may  occur  from  the  relaxed  mus- 
culature and  the  straining  from  constipation.  In  the  typ- 
ical cases  the  stool  itself  shows  little  variation  from  what 
would  be  expected  of  the  normal  child  on  hke  food,  except 
that  it  is  formed.  Flesch^  has  confirmed  the  findings  of 
Helmholz  by  determining  the  presence  of  the  duodenal 
ulcer  by  finding  blood  in  the  stools.  He  thinks  that  these 
ulcers  are  peptic  in  type.  As  suggested  by  Holt,^  Hess  finds 
that  the  duodenal  catheter  may  prove  of  value  in  the  diagno- 
sis of  these  cases  by  showing  blood  on  the  tip. 

Nervous  Symptoms. — In  the  earlier  stages  the  infant  is 
apt  to  be  very  cross  and  irritable.  Sleep  is  disturbed.  In 
hospitals  and  under  proper  regulations  at  the  home,  how- 
ever, it  soon  becomes  peaceful  and  the  sleep  more  profound. 
Convulsions  are  not  often  met  with,  except  the  terminal 
convulsions,  which  may  occur  during  or  at  the  end  of  a 
collapse.  Restlessness  may  cause  the  hair  on  the  occiput 
to  be  rubbed  thin  or  to  disappear  entirely.  There  are  no 
symptoms  on  the  part  of  the  respiratory  tract,  except  per- 
haps a  terminal  pneumonia,  which  may  be  shown  by  the 
presence  of  a  few  crepitating  rales  posteriorly  on  either  side 
close  to  the  spinal  column. 

The  urine  shows  nothing  of  interest. 

The  j[mlse  is  slow,  but  not  weak.  The  rate  is  80  to  100  per 
minute,  which  during  a  collapse  may  be  reduced  as  low  as 
60,  but  even  then  does  not  seem  weak. 

Collapse. — This  comes  on  suddenly,  with  no  premonitory 

1  Jahrb.  f.  Kinderheilk.,  1912,  Ixxvi,  542. 

2  Amer.  Jour.  Dis.  of  Child.,  1913,  vi,  381. 


DECOMPOSITION  199 

symptoms,  and  frequently  without  any  warning  whatever. 
Sometimes  after  exposure  to  cold  or  heat  or  as  the  result  of 
undue  excitement,  but  more  often  without  any  assignable 
cause,  the  child's  skin  becomes  cold  and  cyanotic,  the  face 
becomes  expressionless,  the  extremities  and  head  hang  limp. 
The  pulse  slows  down  and  the  temperature  (rectal)  drops 
to  95°  or  96°  F.  The  breathing  is  labored  and  often  ac- 
companied by  a  little  groan.  Sometimes  convulsions  oc- 
cur which  are  clonic  in  nature  and  of  only  slight  duration, 
with  no  regularity  of  distribution.  This  condition  may 
continue  for  twelve  to  twenty-four  hours,  and  then  the 
child  may  gradually  recover  under  careful  attention. 
Unhappily,  this  results  not  so  frequently  as  we  might  wish. 
More  often  death  supervenes  in  a  few  hours. 

Diagnosis. — Although  apparently  so  free  of  symptoms, 
this  condition  offers  several  points  which  are  of  great  im- 
portance in  diagnosis.  First  of  these  is  the  subnormal 
temperature.  Though  other  than  nutritional  disturbances 
may  cause  a  like  degree  of  marasmus,  few  if  any  wall  show 
a  regularly  subnormal  temperature.  In  conjunction  with 
the  low  temperature  the  slow  pulse  is  to  be  considered, 
though  this  alone  is  not  of  much  value.  The  paradoxic 
food  reaction  is  of  much  value,  especially  when  it  occurs 
without  causing  any  change  in  the  cHnical  picture  other 
than  the  loss  in  weight.  On  the  other  hand,  we  must 
remember  that  in  parenteral  affections  the  tolerance  for 
food  is  usually  reduced,  so  that  a  dyspepsia  may  be  easily 
produced  by  increasing  the  food.  The  absence  of  physical 
findings  other  than  those  due  to  rapid  wasting  may  help 
in  a  diagnosis. 

Differential    Diagnosis. — Tuberculosis    offers    the   most 


200  INFANT   FEEDING 

difficulties.  The  miliary  form  often  presents  the  same 
general  picture  of  malnutrition;  here,  however,  the  tem- 
perature is  usually  elevated  1  to  2  degrees,  and  the  facies 
lacks  the  eager  expression  of  the  case  of  decomposition; 
the  weight-curve  is  steadily  downward  and  there  is  usually 
present  a  shght  diarrhea.  The  stool,  passed  three  to  four 
times  a  day,  is  grass-green  and  may  contain  mucus,  but  rarely 
curds.  Cough  is  often  present,  and  although  there  may  be 
no  rales  over  the  lungs,  still  there  is  a  distinct  note  of  tym- 
panoresonance  on  percussion.  If  the  spleen  is  enlarged, 
the  differentiation  is  not  difficialt.  In  the  tubercular  in- 
toxication, where  there  is  only  a  single  focus  of  tubercular 
infection  and  a  severe  malnutrition  resulting  from  this,  the 
diagnosis  is  almost  impossible.  In  both  forms  the  von 
Pirquet  reaction  is  of  great  value,  since  if  positive  at  this 
age  it  almost  invariably  speaks  for  an  active  tuberculosis. 

Marantic  states  are  the  rule  in  untreated  cases  of  con- 
genital syphilis.  Here  the  difficulties  are  not  so  great  as  in 
tuberculosis.  The  skin  eruptions,  snuffles,  enlarged  spleen, 
and  history  usually  gives  a  strong  clue  to  the  nature  of  the 
disturbance.  In  some  cases  where  a  single  symptom 
arouses  the  suspicion  of  the  physician,  an  energetic  mercu- 
rial treatment  may  confirm  existence  of  syphilis,  since  in 
congenital  syphiUs  the  state  of  malnutrition  seems  to  be 
entirely  the  result  of  the  infection,  and  proper  treatment 
win  produce  results  without  much  attention  to  diet. 

In  the  older  infants  syphilitic  hydrocephalus  may  cause 
great  difficulty  if  it  is  not  remembered  that  a  moderate  hy- 
drocephalus, which  develops  between  the  sixth  and  twelfth 
months,  is  usually  syphihtic  in  nature,  and  practically 
always  accompanied  by  a  severe  state  of  malnutrition. 


DECOMPOSITION  201 

Besides  the  therapeutic  tests  the  Wassermann  reaction  and 
the  Lange  gold  chlorid  reaction  on  the  cerebrospinal  fluid'  are 
of  great  value,  and  should  be  used  in  all  doubtful  cases. 

Chronic  lung  affections  are  not  common  at  this  age,  and 
when  present  are  readily  diagnosed.  After  the  sixth  month, 
or  even  before,  adenoids  may  be  the  direct  cause  of  rather 
severe  malnutrition,  and  should  always  be  considered. 
The  diagnosis  of  adenoids,  as  a  rule,  is  not  difficult,  but  it 
requires  some  judgment  to  determine  just  how  much  of  the 
malnutrition  is  due  to  metabolic  disturbances  and  how  much 
to  respiratory. 

A  neglected  pyelocystitis  may  offer  great  difficulties,  be- 
cause at  a  late  stage  the  temperature  is  often  but  little 
above  normal,  and  the  general  symptoms,  or,  rather,  ab- 
sence of  them,  closely  simulate  a  decomposition.  The 
examination  of  the  urine  clears  up  the  diagnosis. 

Congenital  heart  disease  is  often  accompanied  by  a  most 
severe  state  of  malnutrition,  which  even  under  the  most 
favorable  conditions  may  resist  treatment  of  any  and  all 
kinds.  The  cyanosis  and  heart  findings  readily  determine 
the  source  of  the  trouble. 

Cretinism  may  offer  some  difficulty,  but  when  thought  of 
is  usually  easily  diagnosed. 

In  eczema  the  problem  is  to  determine  in  how  much  the 
malnutrition  is  the  result  of  the  eczema,  and  how  much 
dietetic  errors  may  be  to  blame  for  the  skin  condition. 
The  two  are  most  intimately  connected  and  can  scarcely 
be  regarded  separately.  In  cases  where  vomiting  is  a 
marked  symptom,  pylorospasm  or  pyloric  stenosis  must  be 
excluded.  Pyloric  tumor,  reverse  gastric  peristalsis,  vomit- 
1  Grulee  and  Moody,  Jour.  Amer.  Med.  Assoc,  1913,  bd,  13. 


202  INFANT   FEEDING 

ing  of  large  amounts  of  food/  and  small  ribbon-like  feces, 
when  all  present,  make  the  diagnosis  easy.  Perhaps  the 
most  important  symptom  is  that  of  reverse  gastric  peris- 
talsis, and  this  should  be  looked  for  in  all  cases  of  severe 
and  continued  vomiting.  The  duodenal  catheter  may  here 
prove  of  great  value,  according  to  those  who  have  had  most 
experience  with  it. 

Prognosis. — This,  of  course,  depends  to  a  great  degree 
upon  the  severity  of  the  case  and  the  diet.  Of  the  most 
severe  cases  the  majority  die.  The  younger  the  infant,  the 
worse  the  Qutlook.  The  very  young  infants  cannot  be 
saved  unless  breast-milk  can  be  procured.  The  institu- 
tional infants  seem  to  be  much  less  resistant  than  are 
those  in  private  practice  under  the  same  conditions. 

Symptoms  of  grave  portent  are  cyanosis,  steadily  falling 
weight,  and  continued  gastro-intestinal  disturbance,  such 
as  vomiting  and  diarrhea.  Collapse  is  a  serious  condition 
and  usually  is  followed  by  death.  The  best  gauge  of  the 
less  severe  cases  is  the  reaction  of  the  weight  to  increased 
amount  of  food.  In  those  cases  where  an  amount  of  food 
equal  to  30  to  35  calories  to  the  pound  weight  in  twenty-four 
hours  can  be  taken  without  producing  a  drop  in  weight  or 
gastro-intestinal  symptoms,  the  prognosis  under  the  best 
circumstances  is  good.  Much  depends  upon  the  possibility 
of  obtaining  the  food  best  fitted  for  the  infant,  especially 
breast-milk.  Hygienic  surroundings,  too,  are  of  great  im- 
portance because  of  the  lowered  resistance  to  infections 
in  these  infants.  On  the  whole,  the  condition  is  a  very 
grave  one,  and  requires  in  its  treatment  the  finest  judg- 
ment, not  for  one  or  two  days,  but  often  continued  over 
many  months. 


DECOMPOSITION  203 

Treatment. — Attention  to  every  detail  is  necessary  if  one 
wishes  to  treat  these  cases  successfully.  This  applies  not 
only  to  the  diet,  but  to  every  factor  of  the  daily  existence 
of  the  child.  With  great  care  apparently  hopeless  cases 
can  recover,  while  a  slight  error  in  judgment  or  a  short 
relaxation  in  vigilance  may  undo  the  work  of  many  weeks. 
In  no  disease  of  infancy  is  it  so  necessary  to  have  the  ab- 
solute confidence  and  co-operation  of  the  mother  or  attend- 
ants of  the  child,  and  in  none  is  so  much  patience  and 
caution  required. 

Dietetic  Treatment. — Breast-milk  is  not  only  the  best 
food,  but  in  many  instances  without  it  the  case  is  almost 
hopeless.  This  must  be  given  under  direct  supervision  of 
the  physician,  especially  if  a  wet-nurse  is  employed.  No 
wet-nurse  or  mother  should  give  all  the  milk  from  normally 
functionating  glands  to  one  of  these  infants.  On  the  other 
hand,  if  the  breast  is  employed  for  this  infant  alone  in  the 
early  stages,  such  small  quantities  are  given  that  the  breasts 
become  painful  from  distention,  tend  to  dry  up,  and  the 
milk,  as  a  consequence,  becomes  poor.  To  obviate  this 
difficulty  the  sick  infant  should  be  put  to  the  breast  for  a 
short  nursing  period,  and  immediately  following  a  well 
child  should  be  given  the  breast  until  it  is  drained.  This 
serves  two  purposes,  it  keeps  the  supply  of  milk  in  the 
breast  in  good  condition  and  it  gives  to  the  sick  infant  a 
milk  poor  in  fat,  a  very  desirable  thing.  Many  advise 
that  the  breast  be  given  these  infants  as  often  as  every  two 
hours,  but  in  the  experience  of  the  writer  the  four-hour 
interval  here,  as  elsewhere,  has  given  satisfactory  results. 
At  first  the  infant  should  be  put  to  the  breast  for  two  min- 
utes at  each  nursing,  this  being  gradually  increased  to  five, 


204  INFANT   FEEDING 

and  then  to  ten  minutes  or  longer.  Care  should  be  taken 
that  no  gastro-intestinal  symptoms  develop,  or  if  they  do,  to 
return  to  the  amount  of  food  which  the  infant  can  tolerate. 
Sometimes  it  is  possible  to  obtain  breast-milk  pumped  from 
the  breast  of  a  woman  who  is  nursing  a  normal  infant.  In 
such  cases  it  is  best  to  begin  with  1  ounce  every  four  hours 
and  gradually  increase,  observing  the  same  precautions. 
As  a  rule,  breast-milk  does  not  produce  marked  gains  in 
weight  in  the  first  few  days  or  weeks;  in  fact,  such  are  not 
desirable.  Stolte^  has  been  able  to  produce  distinct  increase 
in  weight  by  the  use  of  breast-milk  combined  with  butter- 
milk. There  must  always  be  a  stage  of  reparation,  during 
which  the  infant's  stools  return  to  normal,  the  temperature 
is  increased  to  the  normal  mean,  and  the  pulse-rate  in- 
creases. Any  attempt  to  produce  a  more  rapid  recovery  is 
much  more  likely  to  be  attended  by  failure  than  by  success. 
If  it  is  necessary  to  nourish  these  infants  on  artificial 
food,  the  chief  indications,  so  far  as  we  know  at  present, 
are  to  reduce  the  fat  and  the  sugars  (milk-  and  cane-)  to 
a  minimum.  This  means,  of  necessity,  a  protein-rich  diet; 
in  other  words,  skimmed  milk.  At  the  very  beginning  this 
should  be  given  to  the  amount  of  1  ounce  to  the  pound 
weight  in  twenty-four  hours,  diluted  with  water  to  the 
required  amount,  and  sweetened  with  saccharin,  the  bottle 
being  offered  every  four  hours.  One  must  not  make  the 
mistake  of  underfeeding  these  infants  too  long,  but  the 
skimmed  milk  should  be  rapidly  increased  to  1^  or  even  to  2 
ounces  to  the  pound  weight  in  twenty-four  hours,  and  malt 
food  or  malt-extract  added,  about  1  teaspoonful  a  day  up  to 
4  to  5  in  twenty-four  hours.     No  one  can  lay  down  hard-and- 

1  Monatsschr.  f.  Kinderheilk.,  1912,  xi  (Orig.),  158. 


DECOMPOSITION  205 

fast  rules  as  to  just  how  rapidly  or  how  slowly  we  must  pro- 
ceed, but  this  must  depend  absolutely  on  the  experience 
and  judgment  of  the  physician  in  charge.  At  best,  this  is 
an  intelligent  experiment,  and  can  be  forwarded  just  so  long 
as  untoward  symptoms,  such  as  those  of  gastro-intestinal 
disturbance  and  the  paradoxic  weight  reaction,  do  not 
make  their  appearance.  If  they  do,  one  must  go  back  and 
start  over  again.  After  the  stage  of  reparation  has  ad- 
vanced under  this  treatment  to  the  point  where  no  symp- 
toms arise  (from  1|  to  2  ounces  of  skimmed  milk  to  the  pound 
weight  in  twenty-four  hours,  to  which  has  been  added  4  to 
5  teaspoonfuls  of  malt-extract  or  malt  food) ,  showing  that 
the  child's  tolerance  for  these  foods  is  distinctly  increased 
(of  course,  during  this  stage  no  gain  in  weight  is  to  be  ex- 
pected), then  we  can  cautiously  add  fat  by  substituting  1 
ounce  of  whole  milk  for  1  of  skimmed,  gradually  increasing 
to  the  point  of  tolerance.  This  point  is  passed  when  the 
stool  becomes  hard  and  white  (or  brown  if  malt  is  in  the 
food),  Uke  that  described  in  weight  disturbance.  When  this 
stool  occurs,  the  amount  of  fat  should  be  decreased  and 
more  malt-extract  added.  In  almost  all  cases  where  the 
food  is  properly  proportioned  the  stool  of  these  infants  is 
formed,  but  on  pressing  it  between  the  layers  of  the  diaper 
it  should  be  salve-Uke  and  not  crumble.  There  is  no  ques- 
tion that  even  under  the  greatest  care  and  with  the  nicest 
judgment  many  cases  will  die  under  this  form  of  treatment. 
No  such  results  as  those  to  be  obtained  from  breast-milk 
nourishment  are  to  be  expected.  On  the  other  hand,  where 
we  cannot  command  the  use  of  breast-milk,  we  must  make 
the  best  of  the  materials  at  our  disposal. 

In  the  opinion  of  the  writer  and  that  of  the  majority  of 


206  INFANT  FEEDING 

those  who  have  used  it,  no  artificial  food  can  compare  in 
these  cases  with  Finkelstein  and  Meyer's  albumin-milk. 
This  is  so  difficult  to  prepare  that  it  is  not  practicable  as  yet 
in  the  average  community.  (See  Albumin-milk,  Chapter  X.) 
If  it  is  to  be  given,  Finkelstein  and  Meyer  advise  that  we 
start  with  about  1  tablespoonful  every  two  hours,  rapidly 
increasing  the  amount  and  lengthening  the  interval,  until 
the  infant  is  fed  every  four  hours  and  to  the  amount  of  3 
ounces  to  the  pound  weight.  In  using  this  the  writer  has 
not  found  it  necessary  to  feed  oftener  than  every  four 
hours,  and  has  usually  begun  with  about  1  ounce  to  the 
pound  weight.  The  carbohydrates  should  be  added  early, 
in  the  form  of  malt-extract  or  malt  food,  and  rapidly  in- 
creased in  amount  up  to  about  IJ  ounces, in  twenty-four 
hours.  The  results  from  this  food  are  often  most  surprising 
and  gratifying,  and  failures  are  more  often  due  to  errors  in 
preparation  than  to  the  composition  of  the  food  itself.  It 
sometimes  requires  many  weeks  for  these  infants  to  gain, 
but  when  they  do  start  the  increase  is  rapid,  and  they  be- 
come, to  all  intents  and  purposes,  normal  infants. 

Hygienic  Treatment. — Too  much  stress  cannot  be  laid 
on  proper  care  in  cases  of  decomposition.  Fresh  air  must 
be  had,  and  this  should  be  neither  too  hot  nor  too  cold. 
I  am  persuaded  that  collapse  and  death  occurs  in  many 
cases  because  these  infants  with  subnormal  temperatures 
are  exposed  to  cold  lake-  or  sea-breezes  in  institutions  de- 
voted to  their  care.  If  the  weather  is  warm,  the  clothes 
should  be  thin  and  light ;  if  it  is  cold,  they  should  be  heavy 
and  thick.  This  pertains  to  outer  wraps.  The  weight  of 
the  undergarments  should  remain  the  same,  only  the  outer 
clothing  being  changed.    Under  no  consideration  should  a 


DECOMPOSITION  207 

case  of  decomposition  be  taken  out-of-doors  on  a  winter's 
day.  On  the  other  hand,  the  room  in  which  it  is  kept  should 
be  thoroughly  aired  at  all  times,  but  at  the  same  time  kept 
warm. 

These  infants  should  not  be  worn  out  by  constant  hand- 
ling, but  should  be  allowed  to  conserve  all  their  energies 
by  lying  quietly  in  the  crib,  the  position  being  changed  from 
time  to  time. 

To  attempt  to  quiet  crying  by  handling  is  a  step  in  the 
wrong  direction,  since  a  day  or  two  of  quiet  in  bed  is  enough 
•in  nearly  all  cases  to  insure  against  future  discomfort. 
Bathing  and  the  other  routine  duties  should  be  even  more 
strictly  attended  to  than  in  the  normal  child. 

Medicinal  Treatment. — The  only  time  when  medicinal 
treatment  is  of  any  use  is  during  a  collapse.  At  this  time 
stimulants  are  most  necessary.  Strychnin  sulphate,  to 
the  amount  of  j^  grain  hypodermically  every  four  hours, 
is  the  best.  Alcohol  is  usually  not  well  borne  because  soon 
vomited.  Caffein  citrate  and  camphorated  oil  may  be  of 
much  value. 

Symptomatic  Treatment. — In  collapse,  besides  stimulation, 
heat  to  the  extremities  and  back  is  of  much  value.  Water 
should  be  offered,  but  is  rarely  taken.  In  vomiting,  stomach- 
washing  and  avoidance  of  all  undue  excitement  are  of  much 
value.  When  stomach  washing  is  resorted  to,  one  must  be 
careful  to  do  this  at  infrequent  intervals  and  must  always 
be  prepared  for  treatment  of  an  acute  collapse.  Very  fre- 
quently if  these  infants  are  allowed  to  rest  quietly  after  the 
bottle  is  taken  the  vomiting  ceases.  The  chronic  atonic 
constipation  is  best  controlled  by  the  use  of  suppositories. 


CHAPTER  XVI 

INTOXICATION 

{Synonyms. — Summer  Diarrhea;  Ileocolitis;  Cholera  Infantum;  Toxi- 
cosis; Infectious  Diarrhea;  Dysentery.) 

Definition. — An  acute  affection  of  the  organism  char- 
acterized by  sudden  onset,  with  collapse,  high  fever,  diar- 
rhea, vomiting,  deep,  pauseless  breathing,  leukocytosis, 
and  mellituria  (lactosuria),  occurring  most  frequently  in 
the  summer  months  and  in  artificially  fed  babies  living  in 
poor  hygienic  surroundings. 

Etiology. — Predisposing  Causes. — This  condition  is  far 
more  prevalent  among  artificially  nourished  infants,  the 
reasons  for  which  will  be  discussed  later.  As  to  age,  the 
idea  that  the  "  second  summer  "  rather  than  the  first  is  the 
one  to  be  dreaded  is  probably  because  a  large  proportion 
of  babies  are  nursed  during  the  first  summer,  while  prac- 
tically all  are,  and  all  ought  to  be,  on  the  bottle  by  the  time 
the  second  summer  comes.  With  this  important  exception, 
intoxications  are  more  common  in  the  first  year  of  life  and 
much  more  fatal.  Sex  and  race  seem  to  make  no  difference. 
Previous  alimentary  disturbances  are  a  very  important 
factor  in  the  etiology.  No  child  develops  intoxication 
without  having  undergone  a  more  or  less  severe  disturbance 
of  its  internal  metabolism  through  nutritional  disorders. 
These  disorders  may  be  slight,  as,  for  instance,  a  weight 
disturbance  or  a  short  period  of  dyspepsia,  or  they  may  be 

208 


INTOXICATION  209 

a  severe  form  of  decomposition,  ))ut  in  many  instances  they 
prepare  the  ground  for  the  harboring  of  the  noxious  chemical 
agent  derived  from  the  food  (or  from  bacteria).  Paren- 
teral affections  of  various  kinds  are  frequently  accompanied 
by  attacks  of  intoxication  which  are  of  alimentary  origin,  but 
these  will  be  considered  elsewhere.  Infections  and  diseases 
which  have  previously  existed,  but  are  not  of  an  alimentary 
nature,  frequently  so  deplete  the  organism  as  to  predis- 
pose to  an  intoxication. 

The  general  predisposing  factors  are  numierous  and  much 
more  definite  than  the  individual.  Heat  undoubtedly 
plays  a  very  important  part.  Most  cases  develop  in  the  hot 
summer  months  and  are  most  numerous  toward  the  end  or 
just  after  a  protracted  hot  spell.  The  exact  nature  of  the 
action  of  heat  is  not  definitely  determined.  It  has  been 
thought  that  the  heat  produced  bacterial  growths  in  milk, 
and  that  by  so  doing  caused  a  decomposition  of  that  food 
which  produced  the  intoxication.  Again,  it  has  been  re- 
garded as  responsible  in  some  unknown  way  for  the  appear- 
ance of  the  dysentery  bacillus,  which  in  turn  has  been  blamed* 
for  so  much  of  the  summer  diarrhea.  Of  late,  however,' 
the  old  idea  that  heat  acts  by  producing  heat-stroke  and, 
therefore,  is  a  direct  cause  of  the  condition  in  question,  is 
gaining  many  adherents.  Aside  from  any  action  which 
heat  may  have  on  the  food,  it  would  seem  that  it  must  have 
some  great  influence  on  the  child  itself,  since  the  body  sur- 
face in  these  infants  is  so  great  in  proportion  to  the  weight 
that  any  external  heat  must  affect  more  deeply  than  in  the 
adult  the  effort  of  the  body  to  adjust  itself  to  external  tem- 
perature. Many  things  besides  the  air  temperature  contrib- 
ute to  the  production  of  heat  or,  rather,  to  its  retention. 

14 


.♦y 


210  INFANT   FEEDING 

One  of  the  most  serious  errors  is  that  of  dressing  these 
babies  too  warmly.  The  idea  that  every  baby  must  have 
a  flannel  band  to  keep  the  "bowels  warm"  is  a  very  prev- 
alent one,  and  the  use  of  this  article  of  clothing,  with  many 
like  errors,  contributes  in  part  to  the  infant  morbidity  of  the 
summer  months.  RietscheP  sums  up  the  effect  of  heat  as 
follows:  First,  by  direct  action  or  acute  heat  intoxication; 
second,  through  chronic  action  by  reducing  the  resistance  of 
the  child;  and,  third,  by  infection  of  the  food,  especially  milk. 
Hot,  poorly  ventilated  rooms,  dirty,  stinking  surroundings, 
failure  to  bathe  the  infant  as  often  as  necessary,  all  lowering 
the  vitality,  help  to  pave  the  way  for  intoxication. 

Active  Causes. — The  active  causes  of  intoxication  may  be 
divided  into  three  classes:  (1)  Some  element  of  the  food,  e.  g., 
sugar;  (2)  decomposition  of  the  food;  (3)  bacterial  infection 
of  the  intestinal  wall.  It  is  altogether  possible  that  each 
one  of  these  may  be  the  cause  in  a  certain  number  of  cases, 
so  that  the  all-important  thing  to  determine  is  not  which 
alone  is  to  blame,  but  rather  the  relative  etiologic  import- 
ance of  each. 

Finkelstein  and  Meyer  have  proved  conclusively  that  the 
milk-sugar  of  the  food  can  of  itself  produce  intoxication. 
This  action  of  milk-sugar  is  aided  greatly  by  the  presence  of 
a  high  fat-content  in  the  food.  The  removal  of  the  sugar 
hastens  the  recovery.  This  action  is  not  confined  to  milk- 
sugar,  but  occurs  with  cane-  and  grape-sugars,  and  less 
often  with  malt-sugar.  In  the  opinion  of  the  writer  this 
sugar  intoxication  or,  as  Finkelstein  and  Meyer  call  it, 
"  ahmentary  intoxication,"  accounts  for  the  majority  of 
the  cases  of  intoxication.     In  how  much  the  inorganic  salts 

1  Jahrb.  f .  Kinderheilk.,  1913,  Ixxviii,  312. 


INTOXICATION  211 

enter  into  this  condition  has  not  as  yet  been  shown.  Tlic 
recent  findings,  in  regard  to  the  pyretic  action  of  sugar  and 
salt  solutions  when  given  subcutancously  (see  Chapter  IV), 
would  seem  to  show  that  the  action  of  sugar  and  salt  must  be 
an  indirect  one. 

Czerny  and  Keller  think  that  the  "toxicosis"  (a  symp- 
tom-complex described  by  them  which  is  identical  with  that 
of  intoxication)  is  due  to  the  decomposition  of  the  food  by 
bacteria,  either  before  ingestion  or  after  its  passage  into 
the  intestinal  canal.  In  their  opinion  the  direct  cause  Hes, 
in  all  probability,  in  the  sphtting  of  the  fats  into  products 
which  are  directly  irritating  to  the  intestinal  canal,  and 
which  when  absorbed  derange  the  internal  metaboUsm. 
They  do  not  bring  any  direct  evidence  of  the  existence  of 
such  decomposition  products,  but  the  opinion  is  supported 
by  animal  experiments. 

Escherich  was  the  first  to  suggest  that  bacterial  infection 
of  the  intestinal  canal  was  the  cause  of  "  summer  diarrhea." 
He  regarded  the  Bacillus  coli  communis  as  at  fault.  Since 
his  time  many  investigators  have  taken  it  for  granted  that 
the  condition  was  of  bacterial  origin,  and  search  in  the  stool 
has  been  made  for  the  causative  agent.  In  this  country 
the  work  of  the  Rockefeller  Institute  was  directed  along 
this  line  in  1902  and  1903,  with  the  result  that  the  Bacillus 
dysenteriae  (Flexner)  was  found  in  a  large  number  of  cases. 
The  dysentery  bacillus  was  found  in  only  20  per  cent,  of  the 
cases  of  ileocoUtis  by  Veeder,  KilduflPe,  and  Denney,^  and  they 
state  that  its  mere  presence  is  not  necessarily  of  etiologic 
value.  The  streptococcus  has  been  championed  by  Jehle. 
Epidemics  have  been  described  by  Moro  and  Escherich  and 
1  Amer.  Jour.  Dis.  of  Child.,  1912,  iv,  75. 


212  INFANT   FEEDING 

by  Finkelstein  in  which  the  Bacillus  acidophilus  seemed  to 
be  the  causative  factor,  and  by  Cooper,  where  the  Bacillus 
pyocyaneus  was  found  in  large  numbers  in  the  stools. 
The  presence  of  the  dysentery  bacillus  in  the  stools  has  in 
many  cases  been  accompanied  by  agglutination  of  that 
organism  by  the  blood  of  the  patient,  but  in  no  case  has 
there  been  any  apparent  benefit  from  the  use  of  antidysen- 
teric  serum.  On  the  whole,  except  in  isolated  epidemics, 
the  bacterial  theory  of  the  origin  of  summer  diarrhea  has 
proved  very  unsatisfactor}^  As  a  causative  factor  of  the 
secondary  symptoms — i.  e.,  of  those  symptoms  which  de- 
velop after  the  onset  of  the  trouble — bacteria  have  not  been 
considered,  and  yet  it  would  seem  that  here  is  their  greatest 
etiologic  value.  An  intestinal  wall  which  has  been  altered 
both  functionally  and  anatomically  by  a  severe  nutritional 
disturbance  would  probably  offer  favorable  ground  for  the 
development  of  bacteria,  which  might  accidentally  be  in- 
troduced per  orem  or  per  rectum,  and  these,  once  having 
gained  a  foothold,  might  easily  produce  secondary  symp- 
toms. The  experience  of  anyone  who  has  had  much  to  do 
with  these  cases  is  that  most  of  them,  if  seen  within  the  first 
few  hours,  will  respond  to  starvation  treatment,  and  in 
twenty-four  to  forty-eight  hours  the  symptoms  of  the  acute 
condition  will  have  disappeared.  This  would  hardly  be  the 
case  if  an  infection  of  the  intestinal  wall  were  the  primary 
lesion.  On  the  other  hand,  the  heaped-up  evidence  of  the 
presence  of  bacteria,  which  must  be  regarded  as  pathogenic, 
is  so  great  as  to  make  one  hesitate  to  disregard  infection 
entirely. 

From  our  present  knowledge  it  is  probable  that  the 
primary  cause  of  intoxication  is  a  dietetic  one,  in  the  yoimger 


INTOXICATION  213 

infants,  due  cither  to  the  sugar  or  salts,  and  in  the  older 
ones  to  more  serious  errors;  decomposition  of  the  food,  in 
all  probability,  is  a  strong  factor  in  the  morbidity,  but  the 
specific  action  of  pathogenic  bacteria  is  secondary  to  the 
primary  nutritional  defect.  It  is  impossible  at  present  to 
estimate  the  real  etiologic  value  of  heat  or  the  nature  of  its 
action,  but  probably  in  most  cases  it  acts  by  materially  re- 
ducing the  resistance  of  the  infant  to  chemical  change,  or 
else  prepares  the  infant's  organism  for  such  change. 

Pathogenesis. — The  exact  nature  of  intoxication  is  by  no 
means  clear.  That  the  condition  is  not  only  intestinal, 
but  metabolic,  is  shown  conclusively  by  the  presence  of 
lactose  (milk-sugar)  in  the  urine  during  the  acute  stages. 
Even  though  the  diarrhea  is  not  violent,  there  is  an  enor- 
mous loss  of  water  through  the  lungs  (Meyer).  Hess^  has 
found  that  the  lipase  of  the  pancreatic  juice  is  deficient,  but 
trypsin  and  amylopsin  are  present  in  large  amounts.  The 
results  of  Holt  and  his  co-workers^  with  a  high  protein  food 
are  suggestive,  but  would  be  of  more  value  if  there  had  been 
less  of  salts,  especially  sodium,  in  the  food  used. 

If  the  diarrhea  is  severe,  as  it  usually  is,  the  loss  of  water 
through  the  bowel  is  accompanied  by  the  various  inorganic 
salts  in  solution,  and  hence  there  is  a  distinct  tendency  to 
demineralization.  The  ammonia-content  of  the  urine  is 
high,  which  speaks  for  an  acidosis.  We  have,  therefore,  a 
severe  disturbance  of  internal  metabolism,  which  shows  evi- 
dence of  acidosis,  loss  of  water  and  salts,  and  a  deficiency 
in  the  sugar-consuming  properties  (Jundell).^    The  relative 


1  Amer.  Jour.  Dis.  of  Child.,  1913,  v,  268. 

2  Ibid.,  1912,  iv,  265. 

» Zeitschr.  f .  Ivinderheilk.,  1913,  viii,  235. 


214  INFANT    FEEDING 

importance  of  these  factors  is  unknown,  and,  in  fact,  may 
vary  probably  greatly  in  the  given  case,  but  they  furnish, 
when  taken  as  a  whole,  valuable  hints  for  treatment. 

Symptoms. — The  onset  is  sudden,  with  rise  of  tempera- 
ture, vomiting,  and  watery  stools.  It  is  always  preceded 
by  some  nutritional  disturbance,  most  often  a  dyspepsia. 
The  temperature  mounts  steadily,  so  that  in  a  few  hours  it 
has  reached  104°  or  105°  F.  Vomiting  may  or  may  not 
be  present,  but  if  present  is  usually  at  the  very  onset  of 
the  disturbance.  The  discharge  of  watery  feces  is  usually, 
but  by  no  means  always,  seen.  Collapse  is  often  seen,  or 
the  whole  may  be  ushered  in  by  convulsions. 

The  fades  is  very  characteristic.  The  eyes  stare  into 
space  and  have  a  sunken  appearance.  The  mouth  is  open 
and  the  hps  seem  parched  and  drawn.  Shght  twitchings 
of  the  muscles  are  seen  about  the  comers  of  the  eyes  and 
mouth.  At  intervals  the  muscles  of  the  face  contract,  as 
if  the  infant  would  cry,  but  very  often  no  sound  is  made, 
and  they  again  relax.  No  attention  is  paid  to  small 
external  stimuli.  This  is  the  facies  which  gives  the  in- 
fant the  "  sick  "  look,  so  often  noticed  and  commented 
on  by  the  attendants;  and  it  is  this  facies  which  leads  the 
physician  to  give  a  graver  prognosis  than  the  severity  of 
the  case  warrants.  Tlie  eyes  soon  become  sunken,  as  does 
the  fontanel. 

There  is  a  rapid  loss  of  weight  in  a  few  hours  from  the  time 
of  onset.  This  usually  amounts  to  about  8  ounces,  but  may 
be  much  greater;  at  times  as  much  as  2  pounds.  This  loss 
is  due,  in  large  measure,  to  the  loss  of  water  (in  the  forms  of 
solution  of  the  various  salts),  and  its  degree  depends,  to 
a  great  extent,  upon  the  severity  of  the  diarrhea.     Much 


Fig.  25.-  liildxical  ion,  sliduin^  t'acics 


Fig.  20. — IntoxitMtion,  showing  faoios  in  more  coinato.sc  .state 
case  as  in  Fig.  25. 


INTOXICATION  215 

of  the  water,  however,  is  lost  through  the  lungs.  After  the 
initial  loss  in  weight  the  supplying  of  water  to  the  system 
may  cause  a  temporary  rise,  but  this,  in  turn,  is  usually 
quickly  followed  by  a  return  to  the  original  low  point. 
After  the  first  loss  the  weight  remains  stationary  or  slowly 
declines,  but  rarely  returns  rapidly  to  the  original  height. 
This  is,  in  part,  due  to  the  necessary  limitation  of  the  food, 
but  any  attempt  to  force  this  up  is  very  likely  to  jjring  on 
another  crisis. 

The  temperature  mounts  quickly  at  the  onset,  usually 
reaching  104°  F.  and  often  going  to  106°  F.  The  return 
to  normal,  if  starvation  diet  is  immediately  instituted,  is 
almost  as  rapid  as  the  rise,  so  that  within  twenty-four  hours 
the  temperature  has  dropped  below  100°  F.,  and  then  or 
later  often  becomes  subnormal.  It  is  not  infrequent  to 
encounter  on  the  second  or  third  day  a  second  rise  of  tem- 
perature; this,  however,  is  never  high,  rarely  over  101°  F., 
but  may  continue  for  some  time,  especially  if  there  is  sugar 
or  a  large  amount  of  sodium  chlorid  in  the  food  (or  admin- 
istered as  a  continuous  saline  enema).  It  is  very  unusual 
for  an  intoxication  of  but  a  few  hours'  duration  to  maintain 
a  high  temperature  if  a  starvation  diet  with  plenty  of  water 
is  administered,  and  any  such  continuation  of  temperature 
should  lead  to  a  diligent  search  for  some  hidden  cause.  If, 
however,  the  intoxication  is  of  some  days'  duration,  it  is 
usual  for  the  temperature  to  continue  high  for  some  days, 
and  even  irregular  for  as  long  as  two  weelvs.  It  is  these 
cases  in  which  secondary  infection  may  play  an  important 
role.  The  temperature-curve  of  an  intoxication  is,  if  all 
circumstances  are  carefully  weighed,  of  much  diagnostic 
value  and  should  be  closely  watched. 


216  •  INFANT  FEEDING 

The  pulse  in  general  follows  the  temperature,  and  is 
rapid  and  snappy;  in  the  neglected  cases,  weak.  A  de- 
crease in  the  intensity  of  the  heart-tones,  a  lack  of  sharp 
distinction,  or  especially  only  a  single  audible  apical  tone, 
are  signs  of  bad  omen  and  call  for  stimulation.  The 
respiration  is  rapid  and  pauseless,  and  has  often  led  to  the 
erroneous  diagnosis  of  pneumonia.  The  upper  and  anterior 
part  of  the  chest  is  high  and  broadened,  due  to  the  conges- 
tion of  the  lungs.  In  the  protracted  cases  along  the  ver- 
tebral column  may  be  heard  the  fine  crackling  rales  of 
hypostatic  pneumonia.  In  intoxication  the  lungs,  to  some 
extent,  act  as  excretory  organs,  throwing  off  an  appreciable 
amount  of  water.  After  the  acute  stage  the  respirations 
rapidly  become  more  quiet,  though  often  being  somewhat 
increased  in  frequency. 

The  gastro-intestinal  symptoms  are  marked.  The  onset 
of  the  attack  is  often  accompanied  by  vomiting,  but,  as  a 
rule,  this  does  not  continue  throughout  the  course,  and  is 
usually  not  an  alarming  symptom.  Eructation  of  gas  is  not 
a  frequent  symptom.  Diarrhea  is  nearly  always  present 
and  is  usually  very  severe.  There  are  ten  to  thirty  or  even 
forty  stools  a  day.  The  stool  is  watery,  sometimes  having 
a  putrefactive  odor,  but  more  often  with  an  odor  resembling 
that  of  a  damp  cellar.  Sometimes  it  is  colorless,  but  more 
often  of  a  light  or  grass-green  color;  at  times,  however,  it 
is  yellow.  Mucus  is  present  in  large  quantities,  as  are  small 
curds  (fat-soaps  or  mucus-balls),  blood  is  rarely  present  in 
the  early  stages,  but  is  found  only  later,  when  the  condition 
has  become  more  or  less  chronic,  and  is  due  to  ulceration 
of  the  intestinal  wall.  The  blood,  when  present,  is  found 
mixed  with  the  mucus.     Pus  is  occasionally  found.     An 


INTOXICATION  217 

intoxication  is  not  necessarily  accompanied  by  a  severe 
diarrhea.  In  fact,  the  stools  may  be  increased  to  only 
four  or  five  a  day,  and  not  rarely  a  severe  constipation  is 
present.  Flatus  is  frequently  passed  with  the  stool  and 
meieorism,  either  at  the  onset  or  more  often  later,  is  a  very 
serious  complication.  This  meteorism  is  due  to  a  partial 
paresis  of  the  bowel  wall  from  the  altered  circulation 
(venous  congestion),  and  hence  is  a  symptom  the  presence 
of  which  is  a  source  of  anxiety.  Prolapse  of  the  rectum  not 
rarely  follows  the  acute  stage  of  intoxication.  In  fat  in- 
fants the  liver  is  often  enlarged,  due  to  fatty  infiltration. 

The  disturbance  in  the  central  nervous  system  is  the  re- 
sult of  venous  congestion.  Usually  these  children  are  only 
semiconscious,  and  respond  to  stimuli  by  a  cry  or  gesture, 
which  shows  the  clouded  state  of  the  cerebral  functions. 
The  child  may,  in  the  severest  stage,  at  times  lapse  into  un- 
consciousness. More  rarely  there  is  distinct  delirium.  In 
some  cases  the  neck  is  held  rigid,  so  rigid,  in  fact,  that  it 
is  most  suggestive  of  meningitis.  Twitchings  of  the  muscles 
of  the  face  and  extremities  are  frequently  seen 

When  disturbed  the  infant  is  Hkely  to  utter  a  weak, 
plaintive  cry,  which  usually  ceases  when  the  irritation  is 
stopped.  During  convalescence  the  child  remains  very 
cross  and  irritable  and  the  sleep  is  hght.  Convulsions  very 
frequently  complicate  intoxication,  and  occur  in  those  chil- 
dren showing  the  spasmophiHc  diathesis  (see  later). 

The  skin  shows  nothing  unusual.  It  is  dry  and  hot 
and  very  pale,  due  to  the  congestion  of  the  internal 
organs.  A  gray-violet  color  denotes  failing  circulation 
and  is  a  bad  sign.  If  an  eczema  was  previously  present, 
it    sometimes   disappears,  only   to    reappear    during   the 


218  INFANT   FEEDING 

convalescence.  The  tissue  turgor  is  markedly  and  rapidly 
reduced. 

The  disturbance  of  the  circulation  is  the  cause  of  the  pallor 
of  the  skin  and  the  cerebral  symptoms,  as  well  as  hypostatic 
pneumonia,  which  often  develops  early  in  the  reparative 
stage.  Meteorism  is  a  result  of  congestion  of  the  intestinal 
waU. 

Heart  weakness  is  a  bad  sign,  and  is  shown  by  weakened 
tones  and  by  hearing  but  one  tone  at  the  apex. 

The  blood  shows  a  leukoc5rtosis  of  15,000  to  20,000,  the 
increase  being  in  the  polymorphonuclear  variety.  Anemia, 
if  present,  is  slight,  and,  on  the  contrary,  the  blood  may 
be  very  concentrated  as  a  result  of  the  rapid  loss  of 
water.  Salge^  has  found  distinct  concentration  of  the  blood 
in  1  case. 

The  urine,  if  obtained  in  the  eariy  stages,  shows  albumin 
and  casts.  Before  all  the  sugar  of  the  food  is  excreted  this 
appears  in  th^e  uriQe.  The  kind  of  sugar  in  the  urine  de- 
pends upon  the  kind  of  sugar  in  the  food.  Lactose  is  most 
common  (from  the  milk-sugar),  but  galactose  and  saccha- 
rose have  been  found.  The  presence  of  sugar  in  the  urine 
denotes  a  serious  disturbance  of  the  function  of  the  in- 
testinal epithelium  and  of  the  internal  metabolism.  Hirsch- 
feld^  found  the  adrenalin  eye-test  positive  in  20  cases,  and 
thinks  that  glycosuria  in  intoxication  is  an  indication  of  the 
involvement  of  the  sympathetic  nervous  system  which  is 
brought  about  by  the  destruction  of  the  albumen. 

Complications. — ^Pneumonia,  either  of  the  hypostatic  or 
bronchial  variety,  is  occasionally  seen.     In  the  former,  the 

1  Zeitschr.  f .  Kinderheilk.,  1912,  iv,  92. 

2  Jahrb.  f .  Kinderheilk.,  1913,  Ixxviii,  197. 


INTOXICATION  219 

lowered  vitality  renders  the  condition  serious.  When 
bronchopneumonia  is  present,  it  is  very  difficult  to  deter- 
mine whether  the  pneumonia  is  a  compHcation  of  the  in- 
toxication or  the  intoxication  of  the  pneumonia.  In  most 
instances  the  latter  is  true.  In  all  cases  the  condition  is  a 
serious  one.  Convulsions  are  likely  to  occur  at  the  onset  of 
the  symptoms  and  greatly  increase  the  danger.  In  severe 
cases  generalized  edema  not  infrequently  occurs,  and,  when 
present,  is  indicative  of  a  serious  condition.  The  exact 
nature  of  the  edematous  process  is  not  understood.  Furun- 
culosis  may  develop  during  convalescence,  as  may  inter- 
trigo and  other  skin  affections.  Pyelocystitis  is  not  often 
a  complication.  It  must  be  remembered  that  the  presence 
of  some  other  disease  does  not  exclude  intoxication,  but 
rather  predisposes  to  it,  so  that  very  often  we  may  regard 
it  as  a  complication. 

Sequelae. — ^The  most  important  condition  resulting  from 
intoxication  is  decomposition.  This  is  especially  likely  in 
young  infants  and  in  those  in  which  the  food  is  poorly  dosed 
after  the  acute  stage  is  over.  By  some  it  is  thought  that  the 
bladder  becomes  infected  with  the  colon  bacillus  from  the 
diarrhea  and  a  pyelocystitis  results.  As  seen  above,  pneu- 
monia may  occur  during  convalescence. 

Diagnosis. — The  chief  diagnostic  symptoms  of  intoxica- 
tion are  the  sudden  onset  with  collapse,  rapid  rise  in  tem- 
perature, vomiting,  deep,  pauseless  breathing,  severe  diar- 
rhea (usually  ten  to  fifteen  green  watery  mucous  stools  a 
day),  leukocytosis  and  albumin,  casts  and  lactose  in  the 
urine.  The  typical  facies  is  of  much  diagnostic  importance 
and  the  general  relaxed  semicomatose  condition  is  suggest- 
ive.    The  quick  reaction  of  the  child,  when  the  food  is 


220  INFANT   FEEDING 

withdrawn  and  water  given  in  large  quantities,  is  not  found 
in  other  affections. 

The  enlargement  of  the  hver,  when  present  after  the  be- 
ginning of  the  attacks  and  absent  before,  is  a  positive 
physical  finding.  In  the  early  stages  the  diarrhea  is  never 
more  severe  in  degree  than  are  the  general  findings;  in 
fact,  the  child  has  the  appearance  of  being  sicker  than  the 
general  symptoms  or  the  underlying  condition  would  seem 
to  warrant,  in  striking  contrast  to  other  affections  pro- 
ducing in  general  the  same  S3niiptoms.  The  absence  of 
physical  findings  is  of  much  value. 

Dififerential  Diagnosis. — Of  the  other  nutritional  disturb- 
ances, only  dyspepsia  is  likely  to  give  much  trouble  from  a 
diagnostic  standpoint.  In  general,  dyspepsia  has  the  same 
symptoms,  only  to  a  much  slighter  degree.  The  fever  is  so 
low  as  to  be  disregarded,  the  diarrhea  is  not  so  severe,  the 
sensorium  is  not  clouded,  leukocytosis  is  sHght,  and  lac- 
tose is  not  found  in  the  urine.  Since  the  disturbances  are 
of  the  same  general  nature,  the  difference  in  the  clinical 
picture  is  a  difference  in  degree  rather  than  in  kind. 

With  those  cases  of  intoxication  having  a  severe  consti- 
pation, weight  disturbance  may  be  confused,  but  the  chn- 
ical  picture  of  the  latter  is  so  much  less  severe  than  is  that 
of  intoxication  that  even  a  superficial  observation  of  the 
case  is  sufficient  to  distinguish  between  them.  The  severe 
cases  of  decomposition  with  diarrhea  are  not  likely  to  pre- 
sent any  difficulty  (see  table,  pp.  222,  223) : 

Perhaps  of  all  the  acute  diseases,  the  clinical  picture  of 
pyelocystitis  most  resembles  that  of  intoxication. 

The  temperature  is  high,  the  leukocytosis  is  marked, 
diarrhea  is  usually  present,  and  there  is  a  general  pallor  of 


INTOXICATION  221 

the  skin.  Pyeolcystitis  occurs  most  frequently  in  female 
infants,  hence  there  is  great  difficulty  in  obtaining  speci- 
mens of  urine  except  by  catheterization.  Again,  if  urine 
is  not  obtained  as  a  routine  measure,  and  it  usually  is  not, 
the  clinical  picture  is  very  confusing.  The  temperature 
of  pyelocystitis  is  usually  very  high,  but  has  marked  re- 
missions of  3  to  4  degrees,  which  occur  at  no  regular  inter- 
vals, but  are  best  distinguished  by  the  suddenness  of  the 
change.  The  temperature  shows  no  tendency  to  reduce 
on  starvation  diet.  Very  frequently,  especially  in  recent 
cases,  within  two  to  four  days  after  the  administration  of 
a  urinary  antiseptic,  the  temperature  drops  to  normal  and 
remains  so.  The  diarrhea,  as  a  rule,  is  not  marked.  The 
general  condition  is  not  so  severe  as  in  intoxication,  and 
there  is  not  the  same  tendency  to  collapse  or  the  same 
clouding  of  the  sensorium.  Physical  examination  is  al- 
most negative,  except  that  in  neglected  cases  there  may  be 
a  tenderness  over  the  kidneys.  The  rapid  breathing  of  the 
type  found  in  intoxication  is  not  encountered.  The  diag- 
nosis is  finally  conclusive  when  the  examination  of  the  urine 
shows  pus-cells  in  large  numbers. 

Otitis  media,  if  accompanied  by  vomiting  and  diarrhea, 
as  it  frequently  is,  has  a  course  not  very  different  from  that 
of  intoxication.  The  temperature  is  often  high,  does  not 
respond  to  starvation  diet.  The  child  cries  and  is  cross 
rather  than  semicomatose.  There  is  no  marked  loss  in 
weight.  Pressure  over  the  external  auditory  meatus 
usually  brings  distinct  manifestations  of  discomfort,  and 
examination  of  the  tympanum  discloses  a  red,  bulging 
membrane.  Paracentesis  is  always  followed  by  a  rapid 
fall  in  temperature  and  subsidence  of  all  symptoms. 


222 


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INTOXICATION 


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224  INFANT  FEEDING 

The  rapid  respiration  may  suggest  pneumonia.  Physi- 
cal examination  is  nearly  always  conclusive,  but  other 
symptoms  may  help.  In  pneumonia  the  sensorium  is 
usually  clear.  There  is  no  marked  loss  in  weight  at  the 
beginning  of  the  disease.  The  temperature  is  high,  but 
is  not  influenced  by  the  starvation  period.  The  cheeks 
are  often  flushed,  and  the  expiratory  grunt  is  quite  char- 
acteristic. Diarrhea  is  a  complication,  and  is,  as  a  rule, 
not  severe. 

Intoxication  often  simulates  very  closely  a  tubercular 
meningitis.  In  the  latter  the  temperature  may  be  high, 
though  more  frequently  it  is  moderate  (101°  to  102°  F.) 
and  irregular.  The  spleen  is  often  enlarged.  Not  infre- 
quently a  tympanic  note  on  percussion  with  fine  crackling 
rales  are  found  over  the  lungs.  The  neck  is  somewhat 
more  rigid  than  in  intoxication,  but  Kernig's  sign  is  very 
often  not  present.  Involvement  of  the  cranial  nerves,  as 
shown  by  strabismus,  etc.,  is  found  only  rather  late. 
A  positive  von  Pirquet  reaction  and  a  cerebrospinal  fluid, 
showing  globulin,  lymphocytosis,  and  especially  tubercle 
bacilli,  make  the  diagnosis  positive.  The  diarrhea,  if 
present  at  all,  is  not  severe,  and  vomiting  tends  to  assume 
the  projectile  type.  Although  a  slight  leukocytosis  may 
be  present  in  tubercular  meningitis,  this  is  never  so  high 
as  in  intoxication. 

The  differentiation  of  acute  miliary  tuberculosis  is  very 
similar  to  that  of  tubercular  meningitis,  except  that  there 
is  no  tendency  to  the  localization  of  symptoms.  The 
sensorium  is  not  clouded;  in  fact,  the  children  seem  rather 
brighter  than  one  would  expect.  The  spleen  is  nearly 
always  enlarged.    The  von  Pirquet  test  is  valuable  ex- 


INTOXICATION  225 

cept  in  the  last  stages,  in  which  it  may  be  negative.  It 
may  be  impossible  to  differentiate  these  cases  on  the  first 
examination,  but  usually  after  a  few  days'  observation, 
the  failure  to  react  to  starvation  diet,  the  character  of  the 
temperature,  and  the  general  advance  of  all  symptoms, 
are  enough,  with  the  Pirquet  reaction,  to  confirm  one's 
previous  suspicions  of  miliary  tuberculosis. 

Almost  every  febrile  condition  accompanied  by  diarrhea 
which  may  occur  in  infancy  may  offer  some  reason  for  con- 
sidering intoxication.  Among  others  may  be  mentioned 
anterior  poliomyelitis,  the  acute  infectious  diseases,  acute 
endocarditis,  typhoid  fever,  and  malaria.  Each  of  these 
may  have  its  special  points  of  resemblance,  but  these  are 
so  remote  or  the  condition  so  unusual  that  it  is  useless  to 
go  into  the  details  of  their  differentiation  here. 

Prognosis. — ^The  prognosis  depends  usually  upon  two 
factors:  the  previous  state  of  health  of  the  child  and  the 
promptness  with  which  proper  treatment  is  instituted. 
In  nearly  all  cases  the  danger  to  life  is  in  the  first  twenty- 
four  hours.  Unfavorable  conditions  are  decomposition, 
age  under  three  months,  and  a  previous  diet  of  denatur- 
ized  food,  such  as  condensed  milk  and  malted  milk.  The 
results  in  infants  previously  fed  on  condensed  milk  seem 
to  be  especially  bad.  Where  intoxication  compUcates 
some  other  disease,  such  as  pneumonia,  the  outlook  is 
exceedingly  grave. 

On  starvation  diet  the  acute  febrile  stage  lasts  rarely 
longer  than  forty-eight  hours  and  is  usually  completed  in 
twenty-four  hours.  The  reparative  stage  may,  however, 
last  many  weeks,  and  depends  upon  the  previous  state  of 
health  and  the  care  with  which  the  food  is  watched  during 

15 


226  INFANT  FEEDING 

this  period.  Any  attempt  to  force  the  food  is  likely  to 
produce  the  opposite  effect  from  that  intended.  A  case 
in  which  the  temperature  falls  to  normal  after  twenty- 
four  hours  and  remains  so,  even  though  a  sHght  diarrhea  is 
present,  gives  a  good  prognosis.  There  is  no  way  of  telling, 
however,  how  long  the  reparative  stage  will  last.  A  fever 
irregularly  or  continuously  high  for  some  days  is  a  serious 
sign,  because  it  denotes  secondary  infection  of  some  kind. 
A  very  severe  watery  diarrhea  at  the  outset  is  an  alarming 
symptom,  and  calls  for  strenuous  efforts  to  overcome  it 
and  its  effects.  Vomiting  is  not  often  a  serious  sjrmptom. 
Meteorism  is  a  symptom  which  is  hard  to  treat,  and  repre- 
sents a  severe  disturbance.  Convulsions  and  pneumonia 
are  complications  which  are  much  to  be  feared. 

Treatment. — Prophylaxis. — Much  can  be  done  to  prevent 
the  occurrence  of  intoxication,  and  it  is  against  this  con- 
dition that  most  of  the  efforts  to  reduce  infant  mortality 
have  been  directed.  There  is  no  question  but  that  these 
efforts  have  done  much  good,  but  they  have  given  the  laity 
the  impression  that  the  solution  of  the  problem  could  be 
attained  by  general  measures,  whereas,  in  its  last  analysis, 
the  solution  Hes  only  in  attention  to  the  individual  child. 
Pure  milk  is  a  very  desirable,  perhaps  necessary,  help  in 
deahng  with  the  infant  morbidity,  but  the  indispensable 
factor  is,  and  must  always  be,  the  properly  trained  phys- 
ician. 

In  caring  for  the  individual  child  we  should  be  careful 
during  the  hot  weather  to  see  that  the  bath  is  properly 
attended  to,  that  the  milk  is  clean  and  fresh,  that  unneces- 
sary clothing  is  removed  (and  this  means  frequently  every- 
thing but  the  diaper),  and  that  the  child  is  kept  in  the  open 


INTOXICATION  227 

air  as  much  as  possible.  The  sleeping  apartments  should 
be  well  aired  during  the  day. 

Most  important  among  the  preventive  measures  is  the 
attention  to  the  composition  of  the  food. 

Above  all,  the  sugar  should  be  reduced  to  a  minimum.  A 
common  error  is  to  reduce  the  sugar  in  the  food  and  allow 
its  use  to  sweeten  water.  The  amount  of  food  should  not 
be  increased  during  the  hot  weather,  and,  in  fact,  it  is  often 
well  to  remove  some  of  the  ingredients,  especially  carbo- 
hydrates. "  Table  "  food  should  under  no  consideration 
be  given,  and  no  attempt  should  be  made  to  force  up  the 
weight  of  a  breast-fed  infant  by  giving  food  other  than  the 
breast. 

Much  has  been  written  in  condemnation  of  pacifiers, 
teething  rings,  etc.,  and  different  shaped  bottles,  but  such 
crusades,  though  creditable,  tend  to  divert  our  attention 
from  the  main  issue — the  food — and  give  an  excuse  to  the 
physician  whose  conscience  will  allow  him  to  grasp  at  such 
straws.  The  general  pubhc,  especially  the  nursing  profes- 
sion, is  quick  to  pick  up  such  palpable  evidence  of  error, 
and  so,  from  an  etiologic  standpoint,  the  pacifier  has  been 
exalted  far  above  its  relative  importance. 

Dietetic  Treatment. — At  the  onset  of  the  intoxication  two 
indications  are  pre-eminent:  first,  stop  food:  second,  sup- 
ply water.  This  is  done  by  giving  in  place  of  the  regular 
bottle  a  like  amount  of  barley-water  sweetened  with  sac- 
charin (1  grain  to  the  quart).  A  bottle  should  be  given 
every  four  hours.  Between  bottles,  water  sweetened  in  the 
same  manner  should  be  offered  the  infant.  Every  attempt 
to  supply  water  to  the  depleted  system  should  be  made. 
Helmholz^  suggests  the  use  subcutaneously  of  an  8  per  cent. 
1  Report  before  the  Chicago  Pediatrics  Society,  Nov.,  1913. 


228  INFANT   FEEDING 

dextrose  solution  in  amounts  of  50  to  100  c.c,  in  order  to 
prevent  the  rapid  loss  in  weight.  After  twenty-four  or, 
at  the  most,  forty-eight  hours  of  this  starvation  diet  we 
should  begin  to  give  some  food.  The  various  constituents 
of  milk  and  carbohydrate  foods  are  irritating  to  the  child 
in  the  following  order:  sugar,  fat,  starch,  and  protein  (of 
cows'  milk);  therefore,  if  we  can  have  a  food  which  con- 
tains only  protein  we  will  fulfil  our  indications  best,  and 
next  to  this  stands  the  starch.  A  food  used  by  the  writer 
for  some  time  consists  of  curds  of  skimmed  milk  suspended 
in  arrow-root  water  or  in  5  per  cent,  gelatin  solution.^  (See 
Chapter  X.)  The  curds  of  about  1|  ounces  of  skimmed  milk 
to  the  pound  weight  in  twenty-four  hours  are  given  in  a  re- 
quisite amount  of  arrow-root-water,  sweetened  with  saccharin. 
The  bottle  is  given  every  four  hours.  Within  twenty-four  to 
forty-eight  hours  about  half  the  skimmed  milk  curds  are  re- 
placed with  a  like  amount  of  whole  milk  curds,  and  then  the 
mixture  replaced  1  ounce  at  a  time  with  skimmed  milk,  and 
this  in  turn  with  whole  milk,  carbohydrates  being  gradually 
added  in  the  form  of  malt-sugar  and  starch,  but  never  milk-  or 
cane-sugar.  The  chief  objection  to  this  method  of  treatment 
lies  in  the  diflSculty  in  preparing  the  food,  but  if  the  directions 
are  carefully  followed  this  need  not  be  great.  The  whole 
period,  from  the  beginning  of  the  starvation  diet  to  the 
substitution  of  milk  for  the  curds  mixture,  should  not  con- 
sume longer  than  a  week.  If  a  good  buttermilk  can  be  made 
this  can  be  used,  giving  substantially  the  albumin-milk. 

Where  it  is  not  deemed  necessary  to  go  to  the  trouble  of 
making  the   curd   mixture,   buttermilk   or   skimmed   milk 
may  be  used.     Commercial  buttermilk  is  not  to  be  thought 
^  Grulee,  Interstate  Med.  Jour.,  1913,  xx,  41. 


INTOXICATION  229 

of,  and  the  preparation  of  buttermilk  for  private  use  from 
the  cultures  on  the  market,  though  apparently  easy,  is  not 
always  a  uniform  process.  Buttermilk  contains  less  milk- 
sugar  than  does  skimmed  milk,  and  hence  is  to  be  pre- 
ferred if  properly  prepared.  After  the  starvation  period 
of  twenty-four  to  forty-eight  hours,  about  1  ounce  of  but- 
termilk or  skimmed  milk  to  the  pound  weight  in  twenty- 
four  hours  should  be  given,  properly  diluted  with  water 
or  barley-water  and  sweetened  with  saccharin.  As  in 
other  conditions,  the  bottle  should  not  be  given  oftener 
than  once  in  four  hours.  This  is  continued  for  perhaps  a 
week,  the  skimmed  milk  or  buttermilk  being  increased  to 
1^  ounces  to  the  pound  weight.  This  is  then  replaced 
every  day  by  1  or  2  ounces  of  whole  milk,  and  during  this 
time  the  carbohydrates  added  in  the  same  manner  as  de- 
scribed above.  In  children  suffering  from  severe  losses  of 
weight,  Stolte^  has  been  able  tq  get  the  best  results  by  a 
combination  of  the  use  of  buttermilk  and  breast-milk. 

In  infants  over  a  year  old  it  is  not  necessary  generally  to 
take  such  precautions.  After  the  period  of  starvation 
diet  the  child  is  given  whole  milk  diluted  with  an  equal 
amount  of  boiled  water,  beginning  with  about  1  ounce  of 
milk  to  the  pound  weight  and  increasing  to  1^  ounces; 
then  cereals  are  added  in  small  amounts.  For  several 
years  I  have  found  it  inadvisable  to  use  albumin-water  or 
eggs  in  any  form  in  these  cases.  Vegetable  soup  containing 
very  little  salt  may  be  given,  but  meat  or  chicken  broth  are 
not  to  be  used  even  during  convalescence. 

If  it  is  possible  to  give  these  infants  hreast-milk  after  the 
starvation  period,  it  is  nearly  always  advisable  to  do  so. 
1  Monatsschr.  f.  Kinderheilk.,  1912,  xi  (Orig.),  158. 


230  INFANT   FEEDING 

The  breast  should  never  be  given  oftener  than  every  four 
hours,  and  the  length  of  the  nursing  period  should  be  lim- 
ited to  one  to  two  minutes  at  first,  and  then  gradually 
lengthened  to  ten  minutes.  At  times  it  is  necessary  to 
pump  the  breast,  centrifuge  the  milk,  or  allow  it  to  stand 
and  remove  the  fat.  As  in  other  disturbances  of  nutrition 
in  the  infant,  breast-milk  is  a  valuable  asset  during  the 
reparative  stage,  but  to  obtain  its  full  benefits  great  caution 
is  necessary. 

Hygienic  Treatment. — Fresh  air  is  a  very  essential  part 
of  the  treatment.  These  children  should  be  kept  out-of- 
doors  where  possible,  otherwise  in  a  well-ventilated  room. 
The  clothing,  in  hot  weather,  should  consist  of  nothing  but 
a  diaper  and  thin  slip.  If  possible,  the  air  should  be  kept 
in  motion  by  an  electric  fan  if  there  is  no  breeze.  Cleanh- 
ness  is  absolutely  necessary,  not  only  by  bathing,  but  by 
careful  attention  to  the  buttocks  after  defecation.  It  is 
well  not  to  disturb  the  child  by  washing  the  mouth,  but  the 
nostrils  should  be  cleaned  at  least  once  a  day. 

Medicinal  Treatment. — It  has  long  been  the  custom  to  ad- 
minister a  cathartic  at  the  onset  of  a  diarrhea,  the  reason 
for  which  is  not  plain.  The  bowel  itself  is  doing  all  in  its 
power  to  excrete  the  noxious  material  which  it  contains  and 
cannot  be  forced  to  do  more.  Any  cathartic  tends  only  to  ir- 
ritate an  already  irritated  mucosa  and  make  matters  worse. 
In  the  case  of  calomel,  which  is  the  cathartic  most  often 
chosen,  the  antiseptic  action  is  so  slight  as  to  be  entirely 
disregarded.  Castor  oil  may  even  increase  the  danger  be- 
cause of  the  fat  in  it.  It  is  more  than  likely  that  calomel 
does  little  harm,  but  it  is  absolutely  useless  and,  therefore, 
need  not  be  given.  It  is  the  custom  of  the  writer  never  to 
give  a  cathartic  in  the  acute  stages  of  a  diarrhea. 


INTOXICATION  231 

Intestinal  astringents  may  rarely  be  useful  in  the  later 
stages  of  secondary  infection,  but  even  here  they  are  of 
doubtful  value.  They  are  usually  given  as  enemas,  in  the 
form  of  tannic  acid  or  the  tannates,  in  a  solution  of  about 
1  or  2  per  cent.,  and  it  is  altogether  likely  that  simple  enemas 
would  produce  just  as  good  results.  Sinclair'  has  obtained 
good  results  by  the  use  of  cultures  of  the  lactic  acid  bacillus. 
In  the  experience  of  the  writer  these  cultures  give  the  best 
results  when  given  in  liquid  form  and  during  the  stage  of 
convalescence. 

Symptomatic  Treatment. — For  the  fever,  hydrotherapeu- 
tic  measures  are  the  only  ones  to  be  considered.  Cold 
sponges  or  even  cold  baths,  if  the  temperature  is  very  high 
at  the  onset,  are  of  much  value.  It  is  well  not  to  have  the 
temperature  of  the  water  for  a  cold  bath  lower  than  90°  F. 
An  ice-cap  to  the  head  is  a  very  simple  and  effective  measure. 
Colonic  flushings  of  tepid  water  are  an  aid. 

When  the  diarrhea  is  very  severe,  so  that  a  stool  is  passed 
every  few  minutes  and  the  infant  is  in  imminent  danger  of 
death  through  rapid  loss  of  fluid,  opium  is  indicated.  This 
is  best  given  in  the  form  of  paregoric  in  doses  in  proportion 
to  the  age  of  the  child  (lUj  to  ij  under  three  months;  three 
to  six  months,  TTliij  to  v;  six  to  eighteen  months,  not  over 
TTlviij),  and  should  not  be  repeated  more  than  once,  and 
never  in  less  than  two  hours.  In  the  later  stages,  when  the 
diarrhea  has  become  more  or  less  chronic,  flushings  offer 
the  best  measure  for  relief.  Perhaps  the  simple  saline 
flushing  will  do  the  work  best  because  it  is  non-irritating. 
The  medicated  flushings,  containing  such  antiseptics  as 
silver  nitrate,  acetozone,  etc.,  have  never  met  with  any  great 
1  Arch.  Ped.,  1913,  xxx,  529. 


232  INFANT   FEEDING 

degree  of  success,  but  may  be  tried  in  severe  cases.  The 
benefit  of  bismuth  in  these  diarrheas  is  doubtful.  When 
given  it  should  be  in  the  form  of  the  subnitrate  or  subcar- 
bonate,  suspended  with  acacia.  Large  doses  are  not  ad- 
visable, 5  grains  every  four  hours  will  give  whatever  bene- 
ficial results  are  to  be  obtained  from  its  administration. 

Vomiting  is  rarely  a  symptom  which  causes  much  dis- 
tress. When  persistent,  stomach-washing  is  of  much  value; 
at  times  even  one  lavage  is  sufficient  to  stop  a  severe  vomit- 
ing. Bismuth  and  cerium  oxalate  act  less  quickly,  but 
produce  very  good  results.  When  eructation  of  gas  is  dis- 
tressing, charcoal  may  be  given. 

Meteorism  is  best  combated  by  means  of  colonic  flushings 
of  normal  salt  solution,  or  of  a  few  grains  of  finely  divided 
charcoal  in  normal  salt  solution.  Care  should  be  observed 
not  to  introduce  too  much  fluid,  for  the  paretic  condition  of 
the  bowel  may  allow  its  distention  and  cause  serious  col- 
lapse from  pressure  on  the  diaphragm.  The  abdomen 
should  always  be  carefully  watched  and  the  amount  of 
fluid  used  estimated.  Sometimes  by  introducing  a  flush- 
ing-tube well  up  into  the  bowel  and  submerging  the  free 
end  in  hot  water  the  gas  passes  out  through  the  water. 
Turpentine  stupes,  if  used,  must  be  very  judiciously 
handled. 

Prolapse  of  the  rectum  is  usually  benefited  most  by  the 
gaining  strength  and  weight  of  the  child.  An  enema  of  1 
to  2  per  cent,  tannic  acid  solution  may  be  given  once  or 
twice  a  day  by  means  of  a  one-piece  rubber  ear-syringe. 
These  syringes  usually  hold  1  ounce,  the  proper  dose  of  the 
solution. 

Collapse  calls  for  prompt  and  effective  measures.    The 


INTOXICATION  233 

continuous  saline  onema  is  of  the  most  value.  The  reservoir 
is  elevated  about  1  to  2  feet  above  the  patient,  and  the 
enema  tube  clamped  off  with  an  artery  forceps  so  that  the 
flow  is  regulated  to  about  1  drop  in  every  two  to  three 
seconds;  the  tube  is  then  introduced  into  the  rectum  and 
allowed  to  remain  there.  In  a  short  time  the  fluid  ceases 
to  be  absorbed  and  is  returned.  The  tube  is  then  removed 
for  a  short  time  and  reinserted.  If  the  diarrhea  is  not  too 
severe,  this  measure  is  very  effective,  but  it  may  in  some 
cases  keep  up  the  temperature.  Subcutaneous  salines  act 
more  quickly,  but  it  is  not  usually  convenient  to  give  them. 
A  solution  of  sodium  chlorid  (7.0)  to  potassium  chlorid 
(0.1)  and  calcium  chlorid  (0.2)  in  100  c.c.  of  water  has  been 
suggested,  but  with  this  the  writer  has  had  no  experience. 
As  a  medicinal  agent  strychnin  sulphate,  ^^^  grain  given 
hypodermically  every  four  hours,  is  good.  Camphorated 
oil,  caffein  citrate,  etc.,  may  be  given  in  the  same  way. 
Alcohol  in  the  form  of  brandy  (TTlv  to  x  in  a  teaspoonful  of 
water  every  four  hours)  or  Tokay  wine  (teaspoonful  in 
equal  amount  of  water)  is  given,  but  may  disturb  the 
stomach. 

The  treatment  of  convulsions  will  be  taken  up  later.  If 
the  delirium  is  marked  and  the  child  extremely  restless, 
chloral  hydrate,  1  to  2  grains  in  an  ounce  of  water,  may  be 
given  rectally.  The  comatose  state  is  best  combated  by 
hydrotherapeutic  measures  and  the  withdrawal  of  food. 
For  the  treatment  of  edema  Comby^  recommends  the  treat- 
ment suggested  by  Hume,  that  is,  the  administration  of  5 
to  10  mm.  of  adrenalin  hydrochlorate  (1 :  10,000)  either  by 
mouth  or  subcutaneously  two  or  three  times  a  day.  Fischer's 
treatment  would  seem  to  be  indicated  in  this  condition. 
^  Archiv.  Med.  lea  Enfants,  1912,  xv,  858. 


CHAPTER  XVII 
SYMPTOMS   AND   THEIR   CAUSES 

ERUCTATION  OF  GAS 

Gas  in  the  stomach  may  come  from  three  sources:  the 
swallowing  of  air,  decomposition  of  food  in  the  stomach, 
and  regurgitation  from  the  duodenum  through  the  pylorus. 
It  is  very  hkely  that  the  swallowing  of  air  and  regurgitation 
of  gas  from  the  duodenum  are  unimportant  factors,  so  the 
chief  process  to  consider  is  the  formation  of  gas  in  the 
stomach  itself  from  decomposition  of  the  food.  It  should 
be  stated,  however,  that  Usener^  regards  the  swallowing 
of  air  as  an  important  cause  of  gas  in  the  stomach. 

When  the  food  is  given  at  such  frequent  intervals  that 
all  of  the  previous  feeding  has  not  had  time  to  pass  the 
pylorus  before  new  food  is  introduced  into  the  stomach, 
there  is  an  accumulation  and  consequent  stagnation  in  that 
organ  which  leads  to  decomposition  and  the  production  of 
gas.  This  is  augmented  if,  for  some  reason,  there  is  a  de- 
layed muscular  action. 

Eructation  is  more  frequent  in  young  infants  and  prob- 
ably more  often  encountered  in  those  fed  at  the  breast. 
It  is  usually  found  with  such  of  the  milder  varieties  of 
nutritional  disturbances  as  dyspepsia,  but  may  be  present 
in  other  forms.  It  is  frequently  accompanied  by  colic, 
especially  in  breast-fed  infants.  Increased  formation  of 
mucus  in  the  nasopharynx  or  bronchi,  when  this  is  swal- 

1  Zeitschr.  f .  Kinderheilk.,  1912,  v,  440. 
234 


SYMPTOMS   AND   THEIR   CAUSES  235 

lowed,   not    infrequently   leads  to    gas    formation    in    the 
stomach. 

Aside  from  regulation  of  the  underlying  condition,  treat- 
ment may  be  directed  to  the  stomach.  vSuch  general 
measures  as  lengthening  of  the  interval  between  feedings 
and  reduction  of  the  sugar-  and  fat-content  are  perhaps  the 
most  valuable.  Stomach-washing,  even  if  only  resorted  to 
once  or  twice,  may  overcome  the  disturbance.  When  ac- 
companied by  vomiting,  medication  in  the  form  of  bismuth 
subnitrate,  suspended  in  acacia  to  which  is  added  powdered 
charcoal  to  the  amount  of  about  5  grains  to  the  dose,  may 
give  rehef.  (The  charcoal  is  not  well  suspended,  so  the 
mixture  must  be  well  shaken  before  using.) 

VOMITING 

Among  the  gastro-intestinal  symptoms  most  frequently 
encountered  in  disturbances  of  nutrition  is  vomiting. 
In  the  infant  several  distinct  forms  can  be  noted,  and  a 
differentiation  is  often  of  much  clinical  value.  In  young 
infants  regurgitation  is  especially  common.  This  consists 
of  a  simple  raising  of  the  food  from  the  stomach,  and  is 
apparently  not  accompanied  by  discomfort.  Another 
type  which  is  seen  is  the  usual  form  of  vomiting  accompanied 
by  more  or  less  discomfort.  Closely  allied  to  this  type  is  the 
ejection  of  small  amounts  of  food  from  the  mouth  as  a  result 
of  a  forceful  eructation  of  gas.  Projectile  vomiting  is  that 
form  where  appreciable  quantities  of  food  are  projected 
with  force,  sometimes  several  feet.  Perhaps  here  it  would 
be  well  to  mention  "  rumination."  This  peculiar  and, 
fortunately,  rare  condition  consists  in  the  regurgitation 
back  into  the  mouth,  after  ingestion,  of  the  food  taken; 
there  the  food  is  held  for  some  time  and  again  swallowed. 


236  INFANT   FEEDING 

This  act  is  seemingly  voluntary,  since  it  is  usually  ac- 
companied by  some  such  act  as  a  strong  suction  on  the 
fingers. 

Regurgitation  of  food  is  most  often  seen  in  infants  under 
three  months  of  age,  and  is  perhaps  more  frequent  in  those 
nourished  at  the  breast.  Mechanical  causes,  such  as  dis- 
turbance immediately  after  nursing,  tight  bands,  etc.,  are 
the  usual  causes.  However,  the  condition  in  very  weak 
infants  may  be  the  result  of  overfilling  of  the  stomach. 
In  many  cases  this  type  of  vomiting  occurs  in  nervous  chil- 
dren. The  material  vomited  is  usually  the  unchanged  milk, 
since  regurgitation  occurs  almost  immediately  after  nursing. 
This  may  have  an  acid  or  ''  sour  "  odor,  due  to  the  mixture 
with  it  of  the  gastric  juice.  As  is  readily  seen,  this  is  not 
a  condition  of  grave  import,  and  removal  of  the  cause  is 
usually  easy  and  quite  sufficient  to  produce  a  cure. 

True  vomiting  is  the  result  of  some  distinct  local  or  general 
disturbance.  It  is  most  frequently  seen  in  cases  of  dys- 
pepsia or  more  severe  alimentary  disturbance,  due  to  some 
grave  error  in  diet.  In  the  experience  of  the  writer  true 
vomiting  has  been  much  more  common  in  breast-fed  than 
in  artificially  fed  infants,  but,  on  the  other  hand,  when  it 
occurred  in  artificially  fed  infants  its  presence  was  the  in- 
dication of  a  more  menacing  condition.  In  part,  this  ex- 
perience is  doubtless  due  to  the  practice  of  using  low  fat 
amounts  in  preparing  food  for  infants,  and  in  advising  a 
four-hour  interval  between  feedings.  One  must  recognize, 
etiologically  at  least,  three  types  of  vomiting:  first,  that 
due  to  disturbance  of  the  stomach  alone;  second,  that  due 
to  nutritional  disturbance  as  a  whole;  and  third,  that  due 
to  parenteral  affections.  The  first  is  most  often  the  result 
of  one  or  both  of  two  errors — high  fat-content  and  short 


SYMPTOMS    AND   THEIR   CAUSES  237 

intervals  between  feedings.  In  the  breast-fed  infant  a 
short  interval  necessarily  causes  a  high  fat-content,  since 
the  breast  is  drained  at  each  nursing,  and  hence  there  is 
always  a  large  amount  of  fat  present  in  the  milk.  Other 
things  being  equal,  the  condition  is  likely  to  be  much  more 
severe  in  artificially  fed  infants,  but,  on  the  whole,  Ls  more 
frequent  in  breast  fed,  since  in  the  artificially  fed  the 
severity  of  the  condition  is  such  that  it  practically  always 
results  in  a  distinct  nutritional  disturbance  if  it  is  not 
properly  treated.  This  form  of  vomiting  may  result,  too, 
from  too  high  sugar-content  (milk-sugar,  malt-extract)  of 
the  food,  but  this  is  less  common  because  of  the  tendency 
to  more  severe  disturbances,  where  the  sugar-content  is  too 
high.  I  have  never  seen  this  caused  by  high  protein-con- 
tent nor  by  large  amounts  of  fluid  to  the  single  nursing. 
In  fact,  I  have  been  struck  by  the  fact  that  if  the  in- 
terval between  feedings  is  sufficiently  long,  even  on  large 
single  feedings,  vomiting  of  this  type  is  distinctly  uncommon. 
The  underlying  condition  is  doubtless  an  irritation  of  the 
mucous  membrane  of  the  stomach,  as  is  evidenced  by  the 
presence  of  large  quantities  of  mucus  in  the  vomitus. 
Vomiting  usually  occurs  from  one-half  hour  to  an  horn- 
after  feeding,  but  may  be  almost  immediate.  The  vomiting 
is  usually  accompanied  by  the  expulsion  of  more  or  less 
gas,  and  consists  of  curds  mixed  with  mucus.  Oftentimes 
there  are  expelled  large  cheesy  masses,  w^hich  are  probably 
the  result  of  stagnation  and  accumulation  of  the  food  of 
former  feedings,  as  a  result  of  the  failure  of  the  stomach  to 
empty  itself  because  of  too  short  intervals.  If  not  recog- 
nized and  treated  early,  this  condition  almost  invariably 
passes  into  the  second  type.  In  the  treatment,  the  best 
and  most  lasting  results  are  to  be  obtained  by  regulation  of 


238  INFANT   FEEDING 

the  diet.  Most  important,  often  alone  siifficient,  is  the 
lengthening  of  the  interval  between  feedings,  where  this 
has  been  less  than  four  hours.  Especially  in  breast-fed 
infants  one  cannot  help  being  struck  by  the  benefit  which 
this  simple  measure  brings.  It  acts  not  only  by  giving  the 
stomach  a  rest,  but  also  by  allowing  the  breast  gland  to 
recover  after  each  nursing,  and  hence  reduces  the  pro- 
portion of  fat  in  the  breast-milk.  The  next  measure  is 
the  correction  of  the  dietetic  error  in  the  composition  of 
the  food.  If  this  be  either  sugar  or  fat,  a  reduction  of  the 
substance  is  productive  of  good  results.  Vomiting  is  rarely 
caused  by  the  amount  of  sugar  contained  in  an  unsweetened 
cows'  milk  mixture,  so  that  usually  admirable  results  may 
be  obtained  by  a  temporary  diet  of  diluted  skimmed  milk. 
This  should  only  be  resorted  to  in  severe  cases,  since  prop- 
erly dosed  whole  milk  dilutions  are  usually  sufficient. 
Where  the  case  is  a  severe  one,  stomach-washing  is  fre- 
quently indicated.  Often  one  washing  is  enough  to  pro- 
duce a  cure;  sometimes  it  must  be  repeated  once  a  day  for 
several  days.  In  cases  accompanied  by  much  gas,  a  mix- 
ture of  charcoal  in  milk  of  bismuth,^  although  of  unsightly 
appearance,  may  give  excellent  results. 

The  second  type  has  been  so  thoroughly  discussed  under 
the  various  nutritional  disturbances  previously  treated  in 
this  work  that  no  further  attention  will  be  given  it  here. 
The  third  type  will  be  taken  up  in  the  chapters  devoted  to 
infant  feedings  in  parenteral  diseases.  One  should  always 
bear  in  mind  the  vomiting  of  intussusception. 

As  to  projectile  vomiting,  it  is  usually  associated  with 

1  About  2  or  3  grains  of  charcoal  to  a  half-teaspoonf ul  of  milk  of 
bismuth  one-half  hour  after  feeding. 


Fig.  27. — Stomach  washing. 


SYMPTOMS    AND   THEIR   CAUSES  239 

acute  cerebrospinal  meningitis,  but  this  disease  is  for- 
tunately not  very  common  during  infancy,  so  that  this 
type  is  not  often  seen.  In  congenital  pyloric  stenosis, 
which  is  seen  most  often  in  very  young  infants,  the  vomit- 
ing is  very  frequently  of  this  type. 

METEORISM 

Meteorism  may  be  due  to  one  or  both  of  two  factors: 
accumulation  of  gas  in  the  intestines  from  decomposition 
of  the  food  and  paresis  of  the  intestinal  wall.  The  sig- 
nificance of  its  presence  depends,  in  large  measure,  upon 
the  general  condition  of  the  infant.  In  a  child  with  in- 
toxication, meteorism  is  a  sign  of  marked  disturbance  of 
the  intestinal  blood-supply  (paresis  of  the  intestinal  wall), 
and  hence  is  a  serious  condition. 

On  the  other  hand,  a  moderate  distention  of  the  abdomen 
in  a  dyspeptic  breast-fed  infant  is  an  aggravating,  but  not 
a  serious,  symptom. 

The  condition  occurs  rather  frequently  in  cases  of  dys- 
pepsia and  intoxication,  and  occasionally  in  weight  dis- 
turbance. At  times  it  may  complicate  a  parenteral  affec- 
tion, such  as  pneumonia. 

Meteorism  is  usually  relieved  by  colonic  flushing,  but 
this  must  be  repeated  once  or  twice  a  day,  since  no  per- 
manent rehef  is  obtained  by  one  washing.  The  fluid  most 
used  is  normal  salt  solution.  If  the  case  is  severe,  finely 
powdered  charcoal  may  be  added.  Intestinal  antiseptics, 
either  by  mouth  or  in  enemas  or  flushings,  are  of  no  special 
value.  In  some  cases  relief  is  obtained  by  introducing  a 
tube  well  up  into  the  colon  and  submerging  the  external 
end  in  hot  water.    Turpentine  stupes  are  sometimes  used, 


240  INFANT   FEEDING 

but  care  must  be  taken  or  these  will  blister  the  skin  of  the 

abdomen. 

DIARRHEA 

This  consists  essentially  of  an  increased  number  of  stools 
in  a  given  time.  The  stools  are  practically  always  of 
softer  consistency  than  normal.  There  is  only  one  imder- 
Ijdng  principle  involved  in  diarrhea,  and  that  is  increased 
muscular  action  in  the  intestines.  This  increased  muscular 
action  is  due  to  irritation  in  some  instances  from  irritating 
substances  found  within  the  canal,  but  it  is  conceivable 
that  a  very  active  peristalsis  may  result  from  the  efforts 
of  the  internal  metabohsm  to  rid  itself  of  poison  through 
the  intestinal  canal.  There  is  a  type  of  diarrhea  found 
both  in  congenital  syphihs  and  miliary  tuberculosis  which 
strongly  suggests  such  a  circumstance  as  the  sole  factor. 

Almost  all  the  diseases  of  infancy,  whether  of  gastro-in- 
testinal  nature  or  not,  may  be  and  frequently  are  accom- 
panied by  diarrhea.  The  condition  is  so  frequent  that  the 
diagnosis  of  diarrhea  so  often  made  conveys  to  the  mind 
absolutely  no  idea  of  the  underlying  condition.  The 
severest  diarrheas  are  almost  always  the  signs  of  an  intoxi- 
cation; on  the  other  hand,  an  intoxication  may  give  only 
shght  diarrhea. 

No  classification  of  diarrhea  is  practicable,  since  so 
many  different  factors  enter  into  the  subject  that  the  at- 
tempt must  result  in  excluding  or  sHghting  some  of  them, 
and  thus  be  a  failure.  One  should  always  analyze  a  diar- 
rhea according  to  its  various  characteristics,  and  in  doing 
this  more  directly  arrive  at  the  nature  of  the  process.  The 
number  of  stools  depends  not  only  on  the  severity  of  the 
irritation,  but  also  upon  the  portion  of  the  intestines  most 


SYMPTOMS   AND   THEIR   CAUSES  241 

affected.  If  the  small  intestine  be  most  involved,  the  diar- 
rhea is  usually  not  so  violent.  The  number  of  stools  are  then 
four  to  five  a  day.  If  the  colon  is  involved  the  number  of 
the  stools  amounts  to  ten  to  twenty  a  day.  If  both  are  in- 
volved, the  result  is,  of  course,  the  larger  number  of  stools. 
The  consistency  of  these  stools  is  determined  usually  by  the 
degree  of  the  intestinal  irritation.  Here,  too,  the  anatomic 
location  of  the  lesion  may  play  some  part,  since  water  is 
largely  absorbed  by  the  colon,  so  that  the  rapidity  with 
which  the  stool  passes  through  the  colon  determines  to  a 
degree  the  amount  of  water  which  it  contains.  It  should 
be  remembered  that  water  is  never  excreted  without  hold- 
ing in  solution  a  certain  quantity  of  the  various  salts,  so 
that  a  severe  watery  diarrhea  is  dangerous,  not  only  because 
it  dehydrates  the  system,  but  also  because  of  its  demineral- 
izing  action.  The  odor  of  the  stool  is  caused  by  the  gases 
formed  by  the  bacterial  processes  in  the  canal.  If  putre- 
factive processes  predominate,  the  odor  is  offensive;  if 
fermentative,  there  is  little  odor.  The  excessive  formation 
of  fatty  acids  gives  a  sour,  rancid  odor.  Putrefaction  is 
rarely  the  result  of  decomposition  of  proteins  of  the  food, 
but  usually  is  due  to  decomposition  of  the  intestinal  mucus. 
The  reaction  is  alkaline  if  putrefaction  predominates;  acid, 
if  femientation  or  fatty  acid  formation  control.  It  is 
possible  that  the  reaction  of  the  intestinal  content  largely 
determines  the  variety  of  bacteria  found,  rather  than  the 
reverse.  The  color  of  the  stool  is  due  to  the  bile  (unless 
some  substance  such  as  beets,  bismuth,  etc.,  has  been  given). 
The  bile-salt  in  the  small  intestine  is  biUmbin.  The 
normal  stool  usually  shows  hydrobilirubin,  a  reduction 
product.     If  the  bilirubin  is  still  further  reduced,  urobilin- 

16 


242  INFANT   FEEDING 

ogen  is  formed.  This  is  colorless  and  is  found  in  the  hard, 
dry,  white  stools  of  a  fat  constipation  (see  Weight  Disturb- 
ance). The  oxidation  product  of  bilirubin  is  biliverdin, 
and  is  the  cause  of  the  green  color  so  frequently  seen  in 
the  diarrheic  stool.  Very  frequently  a  stool  becomes  green 
after  standing,  the  oxidation  taking  place  in  the  air.  It  is 
very  necessary,  therefore,  that  the  stool  should  be  examined 
fresh  or  that  one  should  take  into  account  the  possibility 
of  the  above-mentioned  change. 

Mucus  occurs  in  the  stools  either  in  balls  or  strings. 
The  former  are  the  result  of  peristaltic  action,  and  hence 
come  from  the  small  intestine,  while  the  latter  come  from 
the  colon.  Blood  in  macroscopic  quantities  denotes  ulcer- 
ation at  some  point  in  the  intestines.  A  hard  stool  may 
cause  erosion  just  above  or  at  the  sphincter,  and  the  fecal 
mass  have  blood  on  the  surface.  The  blood  in  ileocolitis 
is  always  intimately  mixed  with  mucus.  Occult  blood  in 
the  stool  from  the  duodenal  ulcers  of  decomposition  (Helm- 
holz,  Flesch)  has  been  found.  When  prolapse  of  the  rectum 
exists,  very  frequently  blood  mixed  with  mucus  is  found  in 
the  stool.  This,  however,  is,  as  a  rule,  only  in  one  place 
and  not  intimately  mixed  with  the  rest  of  the  stool. 

Curds  are  found  in  four  forms,  two  of  which  are  fat  masses 
and  two  from  the  proteins.  The  fatty  curds  occur  as  white, 
granular,  sand-like  masses  resembling  portions  of  the  stool 
of  a  fat  constipation,  or  as  small  flocculent  masses  resem- 
bling soft  curds  of  milk,  but  of  a  yellow  color.  The  protein 
curds  are  most  often  balls  of  mucus.  The  other  protein 
curd  is  the  large,  smooth,  white  or  gray  bean-like  mass, 
sometimes  translucent,  which  frequently  occurs  in  an 
otherwise  normal  stool.  Talbot^  has  recently  shown  by 
1  Arch.  Ped.,  1910,  xxvii,  440. 


PLATH  VIII 


^ 


^ 


''M 


^y^ 


%. 


X 


■/?f3f&Hiuilai*i,  If 


Large  casein  curds  in  otherwise  normal  stool. 


SYMPTOMS   AND   THEIR   CAUSES  243 

animal  experimentation  that  these  curds  contain  cows' 
milk  casein. 

Almost  simultaneously  Brenneman'  and  Ibrahim^  have 
shown  that  if  the  milk  is  boiled  these  masses  disappear  from 
the  stool,  while  if  the  raw  milk  is  given  they  reappear.  Hess' 
believes  that  such  casein  masses  are  formed  in  the  stomach. 

Microscopically,  many  different  kinds  of  bacteria  are 
present.  The  diarrheic  stool  is  Gram  negative,  except  in 
those  epidemics  where  the  Bacillus  acidophilus  has  been 
found  in  large  numbers.  Jehle  regards  the  presence  of 
streptococci  in  large  numbers  in  the  stools  at  the  very 
onset  of  the  diarrhea  as  significant.  In  stools  containing 
the  dysenter}^  bacillus  this  organism  can  frequently  be  seen 
as  an  intracellular  Gram-negative  bacillus. 

The  treatment  of  diarrhea  must  be  the  treatment  of  the 
causal  condition.  No  local  measures  should  be  taken  with- 
out first  diagnosing  the  exact  cause.  In  some  cases  where 
the  stools  are  ver}^  frequent  and  watery  it  is  necessary  to 
check  the  diarrhea  with,  opiates.  In  most  cases,  however, 
it  is  best  to  attempt  to  allay  the  symptoms  with  colonic 
flushings  of  normal  salt  solution  if  general  measures  are 
not  sufficient.  Bismuth  mixtures  are  usually  of  little  value 
and  antiseptic  mixtures  are  neither  necessary  nor  effective. 

CONSTIPATION 
There  is  some  question  about  the  true  meaning  of  con- 
stipation.    Sometimes  in  the  breast-fed  infant  the  amount 
of  food  is  ver}'^  small,  and  as  a  result  the  stool  is  passed 

1  Amer.  Jour.  Dis.  of  Child.,  1911,  i,  341. 
*  Monatsschr.  f.  Ivinderheilk.,  1911,  x,  55. 
» Amer.  Jour.  Dis.  of  Child.,  1913,  v,  457. 


244  INFANT   FEEDING 

perhaps  only  once  in  forty-eight  hours.  In  the  writer's 
opinion  this  is  not  a  true  constipation,  but  rather  an  under- 
feeding. Constipation  presupposes  a  food  residue  in  the 
bowel,  which  for  some  reason  the  intestinal  musculature 
does  not  move  along  as  rapidly  as  in  normal  conditions. 
This  state  may  be  due  to  the  hardness  of  the  fecal  mass  or 
to  the  inertness  of  the  bowel,  or  to  both.  In  most  cases 
it  is  very  hard  to  determine  which  is  more  to  blame  at  a 
given  time.  Primarily,  the  hardness  of  the  feces  usually 
leads  to  constipation  and  resulting  inertness  of  the  intesti- 
nal musculature. 

The  cause  of  constipation  is  very  often  only  indirectly 
due  to  dietetic  errors.  Especially  in  the  breast-fed  baby 
it  is  practically  always  due  to  ill-advised  medication  in  the 
early  weeks  of  life.  Castor  oil  or  colonic  flushings  are  com- 
monly resorted  to  by  the  nurse  without  the  physician's  or- 
ders, or  with  his  sanction  when  the  infant  shows  the  first 
sign  of  colic.  This  procedure  is  repeated  frequently  enough 
so  that  the  bowel  becomes  used  to  this  excessive  stimula- 
tion and  requires  it.  An  atonic  constipation  results.  In 
the  artificially  fed  infant  constipation  is  often  due  to  a  rela- 
tively too  high  fat-content  in  the  food  or  due  to  inertness 
of  the  bowel  following  an  acute  diarrheic  attack.  Con- 
stipation is  much  more  frequent  in  winter  than  in  summer. 

In  the  treatment  the  rule  should  be  never  to  give  drugs 
except  as  a  last  resort.  Of  the  other  measures  at  our  com- 
mand, the  most  useful  are  suppositories.  The  gluten  sup- 
positories rarely  are  sufficiently  irritating  for  our  purpose. 
The  long  glycerin  suppository  is  often  very  effective. 
This  is  introduced  into  the  rectum,  one  end  being  held  in  a 
fold  of  the  diaper.     At  the  home  suppositories  may  be 


SYMPTOMS   AND   THEIR   CAUSES  245 

improvised  from  soap  or  an  oilod  paper-cono.  In  using 
suppositories  one  should  always  be  careful  to  introduce 
them  at  the  same  time  each  day  in  order  to  train  the  bowel 
to  regularity,  a  very  important  feature  of  the  treatment. 
^^'hen  suppositories  are  not  effective,  for  a  few  days  simple 
enemas  may  be  given.  To  the  food  may  be  added  orange- 
juice,  prune-juice,  or  syrup  from  figs.  If  dnigs  must  be 
used,  calomel  and  castor  oil,  because  of  their  rather  drastic 
action,  should  be  reserved  for  the  severest  cases.  Milk 
of  magnesia  in  ^-  to  1-tcaspoonful  doses  once  a  day  is  often 
effective.  \'anous  combinations  of  senna  may  give  relief. 
Olive  oil  is  often  given,  but  in  most  cases  it  rather  aggra- 
vates than  reheves  the  condition,  while  in  others  it  is  re- 
sponsible for  a  mild  dyspepsia.  In  a  few  cases  it  apparently 
is  quite  effective. 


PART   IV 
NUTRITION   IN   OTHER   CONDITIONS 


CHAPTER  XVIII 

THE    PREMATURE    INFANT 

The  premature  infant  presents  problems  due  to  under- 
development. This  underdevelopment  is  not  confined  to 
nor  does  it  predominate  in  the  gastro-intestinal  tract,  but 
affects  the  organism  as  a  whole.  We  have,  then,  the  same 
problem  of  infant  feeding  exaggerated,  ^.  e.,  the  underde- 
veloped gastro-intestinal  tract  required  to  supply  a  rapidly 
growing  organism  and  the  internal  metabolism  to  take  care 
of  the  material  conveyed  to  it  for  use. 

According  to  Budin^  the  premature  infant  is  exposed  to 
danger  from  three  sources — chilling,  improper  dosage  of 
nourishment,  and  infection  from  surroundings  and  at- 
tendants. The  effect  of  the  body  temperature  is  readily 
seen  from  the  tabulation  of  the  mortality  as  taken  from  his 
lectures  (see  p.  247) , 

1  The  Niirsling,  London  (about  1909),  Lectures  1  and  2.    The  result 
of  large  experience  as  put  forth  in  these  lectures,  which  are  freely  quoted 
from  in  the  text,  is  of  inestimable  value  to  one  interested  in  the  subject. 
246 


THE    PREMATURE    INFANT 


247 


Temperature  on  entraooe. 

320C.(90«F.)  or  under.             '=^  ^^T«  F.)'"^" 

Weight. 

Died. 

Lived. 

Mortality. 
Per  cent. 

Died. 

Lived. 

Mortality. 
Per  cent. 

1500  gm.  (3  lb.)  or  less. 

1500  to  2000  gm.  (3- 

4Jlb.) 

101 

38 

2 

1 

98.0 

97.5 
75.0 

70 

71 
9 

2 

12 
4 

97.3 
85.6 

Over  2000  gm.(4i  lb.). 

6 

2 

69.2 

We  see  from  this  table  how  unfavorably  a  low  temperature 
influences  the  premature  infant. 

The  high  mortality  is  very  striking  when  we  know  that 
the  hospital  in  which  Budin  made  his  observations  was  well 
equipped  with  incubators  and  that  the  food  was  suppUed 
by  wet-nurses. 

In  caring  for  the  premature  infant  it  is,  therefore,  very 
necessary  that  the  heat  of  the  body  be  conserved.  This, 
of  course,  is  best  done  by  means  of  the  specially  constructed 
incubators.  These  are  not  often  at  our  disposal,  and  chill- 
ing of  the  infant  even  for  a  short  time  may  be  fatal,  so  that 
removal  of  a  child  to  an  incubator  is  often  inadvisable. 
A  fairly  satisfactory  temporary  incubator  may  be  made  by 
placing  a  small  infant's  bath-tub  or  other  metal  vessel  in  a 
large  vessel  containing  hot  water,  the  smaller  vessel  being 
propped  up  from  the  bottom.  The  water  must  be  kept  at 
a  constant  heat  of  105°  to  110°  F.  The  infant  is  then 
wrapped  in  cotton,  the  whole  body  being  enclosed  ^-ith  the 
exception  of  the  face.  It  is  then  placed  on  a  thick  mass  of 
cotton  in  the  bottom  of  the  smaller  vessel,  covered  with 
cotton  and  surrounded  with  hot-water  bags,  being  careful 


248  INFANT  FEEDING 

not  to  place  these  so  that  their  weight  falls  directly  on  the 
infant.  Under  these  conditions  it  is  very  inconvenient 
to  change  or  nurse  the  infant,  but  the  materials  mentioned 
can  all  be  obtained  at  a  moment's  notice. 

It  is  self-evident  that  no  attendant  should  be  affected 
with  any  disturbance  of  an  infectious  nature.  This  applies 
not  only  to  the  acute  infectious  diseases,  but  also  to  such 
conditions  as  influenza,  nasopharyngitis,  tonsillitis,  etc. 

In  feeding  the  premature  infant  the  first  food  to  be  con- 
sidered is  breast-milk.  If  an  artificial  food  is  to  be  consid- 
ered, the  best  results  have  been  obtained  by  the  writer  with 
albumen  milk. 

In  the  nutrition,  three  things  must  be  considered:  the 
maimer  in  which  the  food  shall  be  given,  the  length  of  the 
interval  between  feedings,  and  the  amount  to  be  given  at  a 
single  nursing. 

Most  of  these  infants  are  unable  to  grasp  the  nipple,  so 
that  we  must  resort  to  pumping  the  breasts  and  giving  the 
milk  with  a  spoon  or  tube.  In  feeding  with  a  spoon, 
great  care  should  be  taken  not  to  feed  so  rapidly  or  in  such 
large  quantities  as  to  cause  choking  and  vomiting.  Feed- 
ing by  gavage  is  very  simple,  but  the  food  must  be  introduced 
into  the  stomach  slowly  and  in  small  quantities.  It  is 
usually  diflScult  to  produce  and  keep  up  the  flow  of  milk  in 
the  breasts  by  artificial  means,  so  that  every  attempt  should 
be  made  to  have  the  infant  take  the  nipple.  In  case  of 
vomiting  some  benefit  may  be  gained  by  setting  the  milk 
aside  on  ice  and  removing  the  fat,  or,  better,  removing  the 
fat  by  centrifuge. 

The  length  of  the  interval  must  be  determined  by  the 
amount  of  food  taken  at  a  single  feeding.    An  interval  of 


THE    PREMATURE    INFANT 


249 


one  and  one-half  to  two  hours  is  usually  employed,  but 
Litzenberg*  has  obtained  excellent  results  with  a  four-hour 
interval,  and  these  results  agree  very  well  ^^ith  the  experience 
of  the  writer. 

As  in  other  conditions,  the  amount  of  food  must  be  deter- 
mined by  the  condition  of  the  child.  Undernourishment  is 
shown  by  a  stationary  or  falling  weight  and  by  cyanotic 
attacks;  overfeeding,  by  vomiting  and  diarrhea.  There  is 
much  disagreement  as  to  the  caloric  value  of  the  food  which 
these  infants  should  obtain.  Birk^  gives  conN-incing  proofs 
that  the  energy  quotient  should  not  exceed  that  of  the  full- 
term  child,  that  is,  100  to  110  calories  per  kilo,  while  Samel- 
son^  states  that  it  should  vary  between  115  and  150.  Budin 
gives  the  following  table  of  the  average  amounts  of  milk 
taken  by  these  infants,  but,  as  he  remarks,  these  represent 
only  average  figures,  and  should  serve  as  a  guide  together 
with  such  other  data  as  may  be  gathered: 


Infants  weighing  leas 

Infants 

weighing 

Infants 

weighing 

than 

1800      gm. 

from   1800  to  2200 

from  2200  to  2500 

(about  4  pounds). 

gm.  (4- 

-5  pounds). 

gm.  (5-5 J  pounds). 

11  Infanta. 

31  Infants. 

25  Infants. 

Second  day . . . 

115  gm 

(4  oz.) 

129  gm 

{A\  oz.) 

ISOgm 

(6  oz.) 

Third  day...  . 

160   " 

(5^  oz.) 

175   " 

(6  oz.) 

2.36   " 

(8^  oz.) 

Fourth  day . . . 

210   " 

Oh  oz.) 

226   " 

(8  oz.) 

295   " 

(lOi  oz.) 

Fifth  day 

225    " 

(8  oz.) 

308   " 

(11  oz.) 

335   " 

dUoz.) 

Sixth  day .... 

250   " 

(8f  oz.) 

324   " 

dUoz.) 

370   " 

(12i  oz.) 

Seventh  day . . 

2S0   " 

(10  oz.) 

335   " 

(llf  oz.) 

375   " 

(12J  oz.) 

Eighth  day . . . 

285   " 

(10  oz.) 

350   " 

(121  oz.) 

385   " 

(13  oz.) 

Ninth  day 

310   " 

(11  oz.) 

380   " 

(13  oz.) 

415   " 

(14i  oz.) 

Tenth  day. . . . 

320   " 

(lUoz.) 

410  " 

(141  oz.) 

425   " 

(15  oz.) 

1  Amor.  Jour.  Dis.  of  Child.,  1912,  iv,  391. 

2  Monatsschr.  f.  Kinderheilk.,  1910,  Lx  (Orig.),  279. 
»  Zeitschr.  f.  Kinderheilk.,  1911,  ii,  IS. 


250  INFANT   FEEDING 

If  these  children  are  to  be  fed  artificially  one  may,  in  a 
fair  proportion  of  cases,  get  good  results  with  the  use  of  al- 
bumen-milk. This  should  be  given  not  oftener  than  every 
four  hours  and  to  the  amount  of  1  ounce  at  a  feeding  (un- 
diluted) at  the  beginning.  This  is  rapidly  increased  to  2 
ounces  and  a  malt  food  added  in  teaspoonful  doses. 


CHAPTER  XIX 
THE    EXUDATIVE    DIATHESIS    (CZERNY) 

Definition. — The  exudative  diathesis  is  a  congenital 
anomaly  of  the  organism  which  usually  affects  all  members 
of  a  family.  At  birth  no  signs  are  present  by  which  its 
presence  can  be  determined,  but  in  the  course  of  a  few 
months  or  even  less  well-defined  tendencies,  such  as  dis- 
tinct predisposition  to  eczematous  conditions  of  the  skin 
and  to  infections  of  the  respirator^'  tract,  are  to  be  noticed. 
All  symptoms  are  exaggerated  by  uncleanliness,  a  high  fat- 
content  in  the  food,  and  a  life  among  nervous  people. 

Etiology. — The  condition,  as  such,  exists,  but  we  as  yet 
do  not  understand  its  exact  nature  or  its  cause.  So  far 
as  is  at  present  known,  its  manifestations  are  confined  to 
childhood,  but  it  is  highly  probable  that  such  an  import- 
ant factor  in  the  health  of  the  child  would  in  some  way 
affect  that  of  the  adult.  It  is  present  more  often  in  the 
city  than  in  the  country,  and  is  so  frequently  a  part  of  the 
life-history  of  the  parents  that  it  may  be  regarded  as  an 
inherited  taint.  No  one  who  is  familiar  with  the  manifes- 
tations of  exudative  diathesis  ^dll  hesitate  to  assert  its  great 
frequency  in  all  classes  and  especially  among  the  city 
poor. 

Symptomatology. — This  condition  may  be  present  in 
any  child,  but  two  distinct  types  present  themselves  which 
seem  to  be  most  often  affected.    The  one  is  the  pale,  puny, 

251 


252  INFANT  FEEDING 

congenitally  delicate  infant;  the  other,  the  fat,  robust,  ap- 
parently healthy  child.  One  thing  is  common  to  all  the 
manifestations  of  this  diathesis,  and  that  is  the  distinct 
tendency  to  increased  severity  from  micleanliness  (hence 
infection),  an  increase  of  fat  in  the  food,  and  an  environ- 
ment which  tends  to  strain  the  nervous  system.  The 
most  important  symptoms  are  those  referable  to  the  skin, 
the  respiratory  tract,  and  body  weight. 

Body  Weight. — After  birth  these  infants  may  remain  sta- 
tionary^ in  weight  for  a  month,  in  spite  of  the  fact  that 
conditions  are  ideal.  After  this  time  the  increase  is  rapid, 
but  they  never  quite  attain  the  normal.  After  removal 
from  the  breast  constipation  quickly  develops,  and  only 
ceases  when  the  fat-content  of  the  food  is  reduced  to  a 
minimum.  This  would  suggest  a  congenital  anomaly  of 
metabohsm.  Much  earUer  than  healthy  children  these 
infants  are  able  to  assimilate  starch,  and  they  gain  well  on, 
and  seem  to  need,  starchy  food.  It  is  never  well  to  attempt 
to  attain  a  rapid  gain  in  weight,  because  this  is  frequently 
followed  by  a  weight  disturbance  or  a  nutritional  disorder 
of  a  severe  degree.  Intercurrent  infections  are  frequent 
and  often  cause  a  weight  standstill. 

Skin  Symptoms. — The  most  frequent  skin  affection  is  seen 
in  the  scalp  and  is  veiy  often  entirely  disregarded.  The 
cradle  cap  is  a  grayish  or  yellowdsh-gray  discoloration  of  the 
scalp  in  the  region  of  the  large  fontanel.  It  is  most  often 
regarded  as  ''dirt,"  and  the  mother's  efforts  are  directed 
toward  its  removal.  Perhaps  for  a  short  time  these  efforts 
may  be  attended  by  success,  but  the  reappearance  of  the 
cradle  cap  is  certain.  In  the  lighter  forms  the  cradle  cap 
consists  of  many  discrete  areas  of  brownish,  grayish,  or 


THE    EXUDATIVE   DIATHESIS    (CZERNY)  253 

grayish-yellow  color  in  the  scalp  covering  the  anterior  fon- 
tanel. These  are  somewhat  scaly  and  can  with  effort  be 
removed.  As  the  condition  becomes  worse,  these  areas 
are  joined  together  by  other  similar  areas,  and  gradually 
the  crust  increases  in  thickness.  As  it  becomes  thicker 
the  color  becomes  more  yellow,  but  at  this  stage  the  whole 
mass  is  quite  dry.  The  next  stage  is  that  of  seborrheic 
eczema,  in  which  the  area  is  much  larger,  sometimes  taking 
up  the  entire  scalp.  The  crusts  are  large,  yellow,  thick, 
and  exude  a  seropurulent  fluid.  Itching  is  not  very 
marked. 

The  skin  eruption  next  in  frequency  is  the  milk  eczema. 
In  very  young  infants  the  cheeks  are  seen  to  be  red.  Or- 
dinarily the  cheeks  of  young  infants  are  not  red,  even  when 
they  are  out  in  the  air,  so  that  the  redness  alone  should  at 
once  attract  our  attention.  On  close  examination  it  is  seen 
that  the  red  area  is  very  definitely  bounded  and  does  not 
gradually  shade  off  into  the  surrounding  skin.  Instead  of 
being  confined  to  the  cheek,  it  passes  backward  along  the 
skin  over  the  zygomatic  process  toward  the  ear.  On  the 
surface  of  this  reddened  area  are  seen  fine  scales.  A  slight 
eczematous  condition  frequently  develops  on  this  area,  be- 
ginning, as  a  rule,  in  the  middle  of  the  cheek.  This  is 
extremely  itchy,  and  infection  from  scratching  may  cause 
an  extensive  fatal  eczema. 

Another  very  frequent  skin  manifestation  is  what,  for 
want  of  a  better  name,  has  been  called  intertrigo.  This 
occurs  in  the  folds  of  the  skin  and  is  most  characteristically 
encountered  behind  the  ears.  It  is  primarily  a  simple  raw- 
ness, but  is  usually  covered  with  a  few  crusts.  Intertrigo 
is  also  found  in  the  folds  of  the  neck  and  in  the  axilla.    A 


254  INFANT  FEEDING 

rawness  in  the  inguinal  folds  without  other  manifestations 
of  exudative  diathesis  is  nearly  always  the  result  of  an  irri- 
tating urine,  and  should  not  be  confounded  with  the  true 
intertrigo  of  this  affection. 

Prurigo  or  strophulus  is  rare  in  this  country.  In  fat 
infants  it  is  found  as  large  wheals,  especially  on  the  but- 
tocks and  extensor  surfaces  of  the  extremities.  In  thin 
infants  the  lesions  are  more  papular.  Itching  depends 
upon  external  conditions  and  the  nervous  constitution  of 
the  child,  but  usually  it  is  present  to  a  very  annoying  degree. 
The  lesion  is  one  which  is  frequently  found  after  infancy, 
and  is  produced,  according  to  Czerny,  by  dietetic  errors. 

Freund^  described  a  peculiar  tendency  of  the  hair  on  the 
top  of  the  head  to  be  directed  upward.  It  is  resistant  to 
all  attempts  at  control.  The  hair  over  the  upper  part  of 
the  forehead  is  very  short,  and  this  gives  the  appearance  of 
a  high  forehead  with  the  hair-line  beginning  well  back. 

Rachmilewitsch^  produced  a  characteristic  skin  reaction  in 
children  with  exudative  diathesis  by  excoriating  the  skin 
and  applying  a  mustard  paste.  There  developed  a  broad, 
white  wheal  with  a  hyperemic  border,  and  there  was  exuda- 
tion at  the  point  of  scarification. 

Respiratory  Symptoms. — Most  characteristic  of  the  symp- 
toms of  the  exudative  diathesis  which  refer  to  the  res- 
piratory system  is  their  tendency  to  repetition.  No  matter 
what  portion  is  involved,  this  same  tendency  is  manifested. 
Repeated  attacks  of  pharyngitis  occur,  which  are  soon  fol- 
lowed by  an  ever-increasing  enlargement  of  the  lymphoid 
tissue  in  the  nasopharynx  and  the  tonsils,  with  resulting 

1  Monatsschr.  f.  Kinderheilk.,  1910,  ix  (Orig.),  62. 
*  Jahrb.  f .  Kinderheilk.,  1913,  Ixxvii,  176. 


THE    EXUDATIVE    DIATHESIS  (cZERNY)  255 

chronic  hypertrophy  and  its  consequences.  Repeated 
attacks  of  folHcular  tonsillitis  is  another  symptom.  This 
involvement  of  the  lymphoid  tissue  of  the  pharynx  and  ton- 
sils is,  according!;  to  Czomy's  idea,  of  secondary  imj)ortance, 
the  primar}'  infection  occurring  not  in  the  lymphoid  tissue, 
but  in  the  mucous  membrane  of  the  nasopharynx.  1  can- 
not partake  of  this  view,  because  I  have  repeatedly  seen 
this  condition  relieved  for  years  by  a  complete  removal  of 
the  adenoid  tissue  and  the  tonsils.  Any  subsequent  en- 
largement of  the  tonsils  was  always  due  to  the  failure  of 
removal  of  the  entire  tonsil  at  the  operation,  -\nother 
condition  (rare  in  my  experience)  which  Czerny  mentions 
is  repeated  asthmatic  attacks.  These  he  beheves  to  be  due 
to  an  acute  bronchitis,  and  the  severity  of  the  asthmatic 
symptoms  to  depend  upon  the  nervous  condition  of  the 
child.  In  exudative  diathesis  the  mucous  membrane  of 
the  air-passages  is  always  more  or  less  involved. 

Gastro-intestinal  Tract. — This  condition  seems  to  be  pecu- 
liarly free  from  gastro-intestinal  S3'mptoms.  The  only 
symptom,  however,  which  appears  and  disappears  without 
any  regard  to  outside  factors  is  the  geographic  tongue. 
This  shows  as  a  wliite  exudate  of  irregular  outline  on  the 
tongue  surface.  Peculiar  to  this  is  the  fact  that  it  never 
retains  the  same  extent  or  shape,  but  changes  from  day  to 
day.  Fetor  ex  ore  may  be  noticed  due  to  decomposition 
in  the  crypts  of  the  tonsils.  Attacks  of  anorexia  occur,  but 
are  rather  the  result  of  a  superimposed  nervous  constitu- 
tion than  to  the  exudative  diathesis  itself. 

Other  Symptoms. — Vulvitis  and  balanitis  are  encountered. 
In  the  eyes,  blepharitis  is  rather  frequent,  and  Czeray  as- 
cribes phlyctenules  to  this  condition  and  not  to  tubercu- 


256  INFANT   FEEDING 

losis  (scrophulosis) .  Whether  this  be  true  in  all  cases  can- 
not at  present  be  definitely  determined,  but  I  have  repeat- 
edly seen  phlyctenular  conjunctivitis  improved  by  placing 
the  child  on  a  carbohydrate  and  vegetable  rich  diet,  a  result 
which  one  would  rather  expect  to  obtain  with  an  addition  of 
fat  to  the  food  if  the  underlying  condition  were  tubercular. 
Lust^  and  Beck^  have  found  an  increase  in  the  cell-content  of 
the  urine. 

Immunity. — These  children  are  very  prone  to  infection 
of  any  kind.  This  is  perhaps  especially  true  of  the  acute 
infectious  diseases.  Every  measure,  such  as  maternal  nurs- 
ing, fresh  air,  etc.,  should  for  this  reason  be  taken  to  raise 
the  resistance  of  the  child. 

Blood. — The  findings  of  Helmholz/  in  examining  the  blood 
of  infants  suffering  with  exudative  diathesis,  are  interesting. 
He  first  found  that  in  the  eczema  which  is  present  in  exu- 
dative diathesis  there  is  an  eosinophilia  amounting  in  the 
active  stage  to  as  much  as  36  per  cent.,  while  in  the  scrofu- 
lous eczema  there  was  a  reduction  in  the  number  of  eosin- 
ophiles.  Benfey*  reports  a  case  where  eosinophilia  existed 
previous  to  the  appearance  of  marked  symptoms  of  exuda- 
tive diathesis.  What  was  more  interesting  was  that  the 
opsonic  index  was  normal  or  increased  in  exudative  diathesis. 

Prognosis. — In  just  how  far  the  presence  of  an  exudative 
diathesis  affects  the  health  of  a  given  child  it  is  very  hard 
to  say.  It  is  undoubtedly  true  that  these  children  have  a 
marked  predisposition  to  infections,  and  that  their  toler- 
ance for  food,  especially  fat,  is  reduced. 

1  Monatsschr.  f .  Kinderheilk.,  1912,  x,  420.  ' 

2  Ibid.,  1913,  xi,  468. 

3  Jahrb.  f.  Kinderheilk.,  1909,  Ixix,  153. 

*  Monatsschr.  f .  Kinderheilk.,  1912,  xi  (Orig.),  421. 


THE    EXUDATIVE    DIATHESIS   (CZERNY)  257 

The  active  symptoms,  such  as  eczema,  etc.,  usually  dis- 
appear toward  the  midtlle  or  end  of  the  second  year.  The 
tendency  to  attacks  of  nasopharyngitis  and  tonsillitis  exists 
long  after  that  time. 

These  children  are  often  of  a  decidedly  nervous  tempera- 
ment and  are  less  able  to  withstand  nervous  shocks,  even 
of  slight  degree,  than  are  normal  children  of  the  same  age. 

As  to  the  outlook  of  continued  ill  health  throughout  life, 
we  can  only  say  that  there  may  be  a  close  relation  between 
this  condition  in  infancy  and  the  so-called  uric-acid  di- 
athesis in  the  adult. 

Treatment. —  Hygienic  measures  are  very'  necessary. 
Fresh  air  is  essential  to  their  health.  Even  in  cold  weather 
the  child  should  be  out-of-doors  many  hours  a  day.  A  good 
plan  is  to  have  the  infant  sleep  out  in  the  sun  (in  cold 
weather)  during  the  day  and  at  night  in  a  well-ventilated 
room.  We  must  endeavor  to  keep  these  children  warm  in 
winter  and  cool  in  summer.  Hardening  processes  are  not 
advisable;  in  fact,  may  do  distinct  harm  by  shocking  the 
nervous  system.  Careful  attention  should  be  paid  to  the 
health  of  the  children's  attendants.  These  should  always 
be  free  from  infections. 

General  rules  of  diet  apply  to  these  cases  as  to  the  normal 
infant.  Certain  tendencies  are  characteristic  and  should 
be  anticipated.  Most  important  of  these  is  the  inabihty  to 
tolerate  milk-fat  in  large  quantities,  or  even,  at  times,  in 
small  quantities.  It  is  often  necessary  to  reduce  this  in 
the  food,  but  rarely  to  remove  it  entirely. 

There  is  not  the  same  intolerance  for  cod-liver  oil,  and 
this  may  be  given  in  small  doses.  The  tolerance  for  starch, 
on  the  other  hand,  is  increased.     Appreciable  quantities 

17 


258  INTANT   FEEDING 

can  be  taken  with  advantage  as  early  as  the  third  month. 
Breast-milk  is  best  for  these  infants  because  it  tends  to 
keep  up  the  resistance,  but  it  often  is  advisable  to  substi- 
tute one  feeding  of  a  starch  mixture  for  one  nursing 
period. 

Toward  the  end  of  the  first  year  in  the  severer  cases 
gruels  may  be  given  in  place  of  one  or  two  milk  feedings. 

During  the  second  year  all  fatty  foods  should  be  avoided. 
Eggs  should  not  be  given.  Only  in  rare  instances  is  it 
advisable  to  give  over  1|  pints  of  milk  in  twenty-four  hours. 
Vegetables  of  almost  all  kinds,  but  especially  spinach,  beets, 
and  carrots,  should  be  given.  Oranges,  apples,  prunes,  and 
figs  are  well  taken.  Cereals  of  all  kinds  should  form  the 
bulk  of  the  diet. 

Medicinal  treatment  is  to  be  avoided  chiefly  because  of 
the  effect  it  has  on  the  nen^ous  system  of  the  child.  Drugs 
should  be  given  only  to  overcome  temporary  disturbances 
and  not  in  the  form  of  tonics.  For  this  reason  there  is 
some  question  as  to  the  usefulness  of  cod-Hver  oil. 

These  children  should  early  be  taught  to  play  with  others, 
and  not  be  confined  to  the  company  of  adults  or  of  children 
of  the  same  family.  All  reference  by  the  parents  to  the 
child's  ills  should  be  carefully  avoided  in  its  presence,  and 
too  much  sjTupathy  for  small  reason  should  not  be  given. 
In  no  other  wa}^  will  one  be  able  to  develop  a  normal  ner- 
vous system  in  a  case  of  exudative  diathesis. 


CHAPTER  XX 
THE    SPASMOPHILIC    DIATHESIS' 

{Synonyms. — Tetany;  Spasmophilia;  Convulsions.) 

Definition. — ^The  spasmophilic  diathesis  is  a  condition 
characterized  by  an  increased  electric  irritability  and  a 
tendency  to  spasm-like  contraction  of  one  or  more  groups 
of  muscles. 

Etiology. — The  spasmophilic  diathesis  rarely  manifests 
itself  in  the  breast-fed  infant.  It  is  more  often  seen  in  those 
children  whose  diet  has  been  rich  in  fat  and  who  have  had  a 
resulting  fat  constipation.  More  cases  are  seen  in  the  spring 
and  fall  than  in  the  summer,  although  almost  invariably 
the  attacks  are  preceded  by  gastro-intcstinal  disturbances; 
these  latter,  however,  may  not  be  of  a  severe  nature. 
From  the  frequency  of  their  occurrence  in  the  same  indi- 
vidual and  the  apparent  disturbance  of  the  calcium  metab- 
olism in  each,  there  seems  to  be  a  very  close  relation  be- 
tween the  spasmophilic  diathesis  and  rickets. 

Manifestations  of  the  condition  occur  more  frequently  in 
children  after  the  age  of  six  months  up  to  two  years,  but 
Rosenstern'^  has  recently  called  attention  to  its  frequent 
combination  with  congenital  debility,  and  Kehrer^  reports 
6  cases  of  tetany  in  the  newborn. 

*  It  is  the  intention  of  this  article  to  discuss  the  subject  only  in 
so  far  as  it  is  of  interest  from  the  standpoint  of  infant  feeding.  This 
will  be  true  also  for  the  chapters  on  Rickets,  Scurvy,  etc. 

2Zeitschr.  f.  Kinderheilk.,  1913,  viii,  171. 

3  Jahrb.  f.  Ivinderheilk.,  1913,  Ixxvii,  629. 

259 


260  INFANT   FEEDING 

The  exact  nature  of  this  condition  Is  not  known.  The 
occurrence  of  tetany  In  animals  after  removal  of  the  para- 
thyroid glands  has  had  several  investigators.  Escherich^ 
attempts  to  connect  tetany  in  the  infant  with  lesions  of  the 
parathyroid  glands.  However,  no  definite  relation  between 
the  two  as  yet  has  been  proved,  since  many  cases  have  been 
reported  in  which  hemorrhage  in  all  the  parathyroid  glands 
could  be  demonstrated,  and  yet  no  spasmophiHc  symptoms 
had  occurred  during  life.  It  is,  of  course,  possible  that  in 
these  cases  the  elements  of  the  parathyroid  secretion  were 
made  up  in  some  other  way.  But  certainly  it  cannot  be 
positively  asserted  that  there  is  a  definite  relation  between 
lesions  of  the  parathyroid  gland  and  the  occurrence  of 
symptoms  of  the  spasmophilic  diathesis. 

As  to  whether  the  condition  is  due  to  an  absolute  or 
relative  reduction  of  the  calcium  in  the  system,  still  more 
doubt  may  be  expressed.  The  administration  of  the  cal- 
cium salts  (especially  calcium  lactate)  has  in  some  cases 
overcome  the  convulsive  tendency,  while  in  others  there 
has  been  no  effect  whatever  (Haskins  and  Gerstenberger)  .^ 
In  the  case  of  Haskins  and  Gerstenberger  no  disturbance  of 
calcium  was  present.  Reuss^  thinks  that  the  condition  is 
due  to  a  disturbance  in  the  relation  between  the  calcium 
and  magnesium  on  the  one  side  and  sodium  and  potassium 
on  the  other,  but  the  writer^  has  been  unable  to  find  definite 

evidence  of  variation  in  the  formula   jv^^  +k'' 

Liefmann^  has  recently  shown  a  distinct  increase  in  acetone 

1  Die  Tetanie  der  Kinder,  Vienna  and  Leipzig,  1909. 

2  Jour.  Exp.  Med.,  1911,  xiii,  No.  3. 

3  Zeitschr.  f.  Kinderheilk.,  1911,  iii,  1. 

« Amer.  Jour.  Dis.  of  Child.,  191.3,  v,  205. 
6  Jahrb.  f.  Kinderheilk.,  1913,  Ixxvii,  125. 


THE  SPASMOPHILIC   DIATHESIS  261 

excretion  in  the  urine  during  the  manifestations  of  spasmo- 
philia, but  was  able  to  determine  no  parallelism  between  the 
height  of  the  acetone  excretion  and  electric  and  mechanic 
irritability. 

From  the  action  of  the  various  salts  on  the  infant's  or- 
ganism and  on  that  of  animals,  our  suspicions  are  directed 
strongly  toward  that  portion  of  the  food.  It  is  a  well- 
known  fact  that  to  a  degree  the  action  of  certain  of  these  is 
antagonistic  to  that  of  others.  It  is,  therefore,  not  at  all 
improbable  that  the  condition  may  be  due  to  a  disturbance 
in  the  relative  amounts  of  these  in  the  tissues.  The  whole 
subject  is  so  indefinite  that  we  may  draw  no  conclusions 
which  will  give  us  definite  indications  for  dietetic  treat- 
ment. 

Symptoms. — The  presence  of  the  convulsive  tendency  is 
shown  by  the  increased  electric  irritability.  For  testing 
this  a  milliamp^remeter  is  necessary  which  will  register  to 
fractions  of  a  milliampere.  A  galvanic  current  is  used. 
One  electrode  is  placed  on  the  abdomen,  the  other  just  above 
the  crease  of  the  elbow  over  the  median  nerve  (or  on  the  leg 
over  the  peroneal  nerve) .  The  amount  of  current  necessary 
to  produce  the  slightest  twitch  of  the  index-finger  (or  great 
toe)  is  then  recorded.  The  cathode-closing  contraction 
may  be  reduced.  Most  typic,  however,  is  the  cathode- 
opening  contraction.  Where  this  is  produced  by  less  than 
5  ma.  of  current  it  may  be  regarded  as  pathologic;  over  5 
ma.,  as  normal.  The  anode-opening  contraction  is  produced 
by  less  current  than  is  the  anode-closing  contraction. 

Clinically,  this  hyperirritability  may  remain  latent  for 
some  time,  in  fact,  may  never  be  accompanied  by  clinical 
symptoms,  but  usually  at  some  time  or  other  these  develop. 


262  INFANT   FEEDING 

They  usually  appear  in  one  or  more  of  four  forms:  convul- 
sions, earpopedal  spasm  (tetany  in  the  restricted  meaning 
of  the  term),  laryngospasm,  or  rotary  head  spasm. 

The  spasmophilic  convulsion  is  chiefly  characterized  by 
its  tendency  to  repetition  (as  many  as  seventy  convulsions 
in  twenty-four  hours  being  noted)  and  by  the  frequent  se- 
rious involvement  of  the  respiratory  muscles.  It  is  fre- 
quently accompanied  by  the  peculiar  crow  characteristic  of 
laryngospasm.  Laryngospasm  is  of  common  occurrence,  and 
though  alarming,  is  not  serious,  except  in  so  much  as  it  shows 
the  disposition  toward  general  convulsive  seizures.  Car- 
popedal  spasm  and  rotary  head  spasm  are  rarer  manifesta- 
tions of  the  condition. 

Treatment. — As  an  assistance  to  dietary  treatment,  at- 
tention to  the  hygienic  surroundings  is  very  important. 
Fresh  air  is  very  necessary.  These  infants  should  never  be 
kept  in  hot,  poorly  ventilated  rooms,  nor  should  they  be 
allowed  to  remain  dirty. 

It  is  a  well-known  fact  that  a  purely  carbohydrate  food 
decreases  the  convulsive  tendency,  but  this  cannot  be  con- 
tinued for  more  than  a  few  days  without  serious  disturbance 
of  the  infant's  nutrition.  It  is,  therefore,  necessary  to 
give  milk  or  other  food.  In  these  cases  the  writer  has 
applied  a  parallel  treatment  to  that  outlined  for  intoxica- 
tion. The  curds  of  milk  are  suspended  in  arrow-root- 
water  and  given  in  about  the  amounts  specified  there.  In 
the  spasmophilic  diathesis  it  makes  no  difference  whether 
the  curds  from  skimmed  milk  or  whole  milk  are  used. 
It  is  obviously  better,  therefore,  when  the  nutritional  dis- 
turbance is  only  sHght  to  use  the  curds  of  whole  milk.  In 
several  cases  there  has  been  a  distinct  cessation  or  better- 


THE  SPASMOPHILIC   DIATHESIS  2G3 

mcnt  of  symptoms  on  this  food,  with  a  regular  return  to 
their  former  intensity  when  whey  was  added.  After  care- 
fully studying  several  cases  the  writer  is  convinced  that 
before  a  certain-  period  in  the  convalescence  is  reached,  the 
addition  of  whey  to  the  food  increases  the  tendency  to  con- 
vulsive seizures  in  many  cases.  It  is  very  hard  to  explain 
this  action  from  our  present  knowledge  of  the  etiology  of 
the  spasmophilic  diathesis,  but  it  may  be  that  the  calcium 
is  absorbed  in  relatively  greater  quantity  than  the  sodium 
and  potassium,  since  the  latter  are  materially  reduced  in 
the  curd  mixture,  while  the  former  is  not  so  markedly 
affected.  It  should  be  noted  here  that  ZybelU  was  able  to 
determine  no  regular  effect  of  changes  in  diet  on  electric 
irritability  in  spasmophilia.  He  has  used,  however,  different 
material  from  that  of  all  other  writers  on  the  subject.  Be- 
rend^  has  obtained  excellent  results  by  injecting  subcutane- 
ously  an  8  per  cent,  solution  of  magnesium  sulphate.  This  is 
given  in  amounts  of  15  to  20  c.c.  and  repeated  in  a  few  hours 
if  thought  advisable.  Usually,  however,  one  injection  a  day 
is  sufficient. 

Finkelstein  has  shown  that  cod-liver  oil  and  phosphorus 
gradually  but  surely  reduced  the  electric  irritability.  This 
should  be  given  to  the  amount  of  1  teaspoonful  of  cod- 
liver  oil  containing  -^^jj  grain  of  phosphorus  three  times  a 
day.  Since,  as  Schabad^  has  sho-^-n,  cod-liver  oil  probably 
increases  the  retention  of  calcium,  it  is  possible  that  the 
benefit  obtained  from  their  use  in  the  spasmophilic  diathesis 
may  be  explained  in  this  way. 


•  Jahrb.  f.  Ivinderheilk.,  1913,  Ixxviii,  Erganzungsheft,  29. 

2  Monatsschr.  f.  Ivinderheilk.,  1913,  xii  (Orig.),  269. 

3  Ibid.,  1911,  X,  12. 


264  INFANT   FEEDING 

For  the  acute  convulsions  it  is  frequently  necessary  to 
use  sedatives.  The  best  of  these  is  chloral  hydrate.  This 
should  be  given  rectally,  1  to  2  grains  in  1  ounce  of  water. 
In  order  to  control  the  condition  at  first  2  to  3  grains  are 
usually  sufficient,  though  it  may  require  as  much  as  5 
grains  in  a  child  over  a  year  old.  After  the  initial  dose  1 
grain  every  four  hours  is  nearly  always  enough  to  keep 
the  convulsions  under  control.  One  should  never  cease  the 
use  of  this  abruptly,  but  should  gradually  lengthen  the  in- 
terval between  doses.  At  times,  where  quick  action  is 
necessary  and  the  convulsions  are  very  severe,  it  is  neces- 
sary to  use  morphin  or  even  chloroform.  To  arouse  the 
child  from  a  generalized  convulsion  which  has  especially 
affected  the  respiratory  muscles,  dipping  it  from  a  tub  of 
cold  water  to  a  tub  of  hot  water  will  often  stimulate  res- 
piration sufficiently  so  that  if  frequently  repeated  the  Hfe 
will  be  eventually  saved.  One  should  never  despair  until 
the  heart-tones  can  no  longer  be  heard. 


CHAPTER  XXI 
THE    NERVOUS    INFANT 

A  NERVOUS  infant  is  one  which  reacts  with  abnormal 
acuteness  to  external  stimuli,  especially  to  those  directed 
toward  the  higher  cerebral  functions.  Some  slight  incon- 
venience may  produce  a  spell  of  crying  or  the  crying  may 
be  unusually  prolonged  or  intense.  Again,  the  laugh  may 
be  excessive.  The  slightest  cry  or  laugh  may  produce 
vomiting,  or  after  a  day  of  severe  nervous  stress  the 
number  of  stools  may  be  increased. 

There  are  undoubtedly  many  congenitally  neurotic  in- 
fants, but  the  most  evident  form  is  seen  only  in  those  where 
the  condition  has  been  augmented  by  spoiling  the  child 
with  the  attentions  of  fond  parents  or  guardians,  and  also 
(not  infrequently  a  result  of  the  same  attitude)  the  dis- 
turbance of  the  nutrition  from  overfeeding.  These  infants 
are  the  most  prone  to  cry,  and  they  are,  therefore,  the  most 
apt  to  be  petted.  This  constitutes  the  vicious  circle, 
which  must  have  its  effect  not  only  on  the  psychic,  but  also 
on  the  physical,  condition. 

When  these  infants  become  sick,  it  is  ver}^  hard  to  judge 
just  how  much  of  the  clinical  picture  is  due  to  the  neurotic 
condition.  For  instance,  the  newborn  baby  suffering 
from  undernourishment  shows  very  httle  tendency  to  loud 
crying,   but  should  this  child  be  neurotic,  it  is  difficult 

265 


266  INFANT   FEEDING 

to  determine  whether  or  not  the  cry  is  from  hunger  or  from 
coHc. 

Occasionally  an  infant  vomits  or,  rather,  "  spits  up  " 
some  of  its  food,  even  though  this  be  of  such  a  composition 
and  amount  that  we  are  certain  in  the  given  case  that  it  is 
not  irritating  to  the  stomach.  This  child  is  almost  cer- 
tain to  show  other  neurotic  symptoms.  These  and  many 
other  circumstances,  such  as  starting  at  the  slightest  sound, 
restlessness  in  bed,  etc.,  might  be  mentioned. 

All  these  symptoms  are  exaggerated  by  nutritional  dis- 
orders of  the  less  severe  kind,  as  weight  disturbance  and 
dyspepsia.  Two  articles  of  food  seem  to  be  especially  act- 
ive in  increasing  the  nervous  symptoms — ^the  fat  in  fat 
constipation  and  the  sugar  in  dyspepsia.  In  the  breast-fed 
infant  the  most  frequent  cause  of  nervous  manifestations 
is  irregular  and  frequent  nursing,  whether  these  produce 
colic  or  not.  Nutritional  disturbances  are  most  active  in 
accentuating  the  nervousness,  and,  as  in  so  many  other 
conditions  of  infancy,  the  diet,  therefore,  assumes  prime 
importance,  not  in  so  much  as  to  give  a  specific  treatment, 
but  rather  in  a  prophylactic  way,  by  preventing  nutritional 
disturbances  and  hence  nervous  symptoms. 

Treatment. — Regularity  in  all  the  activities  of  the  infant 
is  perhaps  the  most  important  thing  in  the  treatment  of  the 
nervous  child.  The  food  should  be  given  at  a  set  time  each 
period.  The  child  should  be  taught  to  sleep  at  a  certain 
time  each  day.  The  stool  should,  as  far  as  possible,  be 
passed  at  the  same  hour.  The  bath  should  be  given  and 
the  infant  weighed  in  the  morning  at  the  same  hour. 
Absolute  regularity,  with  no  undue  excitement  caused  by 
the  active  admiration  of  so-called  friends  and  overfond 


THE    NERVOUS    INFANT  267 

parents,  is  very  necessary  to  the  comfort  of  the  nervous 
child.  All  these  act  by  resting  the  mind  and  steadying  it 
with  a  daily  invariable  routine. 

Fresh  air  is  most  beneficial.  A  child  which  is  cross  and 
fretful  in  the  house  will  frequently  sleep  soundly  if  put  in 
the  open  air.  This  is  especially  true  if  the  weather  is  cool. 
An  out-door  life,  with  sleep  out-of-doors  except  in  extreme 
weather,  is  a  splendid  tonic  for  the  nervous  infant.  Strict 
attention  should  be  paid  to  the  bath  and  cleanliness.  A 
wet  diaper  will  not  infrequently  be  the  cause  of  a  severe 
crying  spell. 

As  previously  stated,  the  diet  should  contain  little  of 
fats  or  sugars,  certainly  not  enough  of  these  to  produce  even 
slight  nutritional  disturbances.  Starches  are  well  taken 
care  of  and  have  no  irritant  action.  In  the  infant  over  a 
year  old,  cereals  and  vegetables  should  form  most  of  the 
food,  the  milk  being  reduced  to  1|  pints  a  day  and  no 
eggs  or  meat  being  given.  The  most  essential  thing  is  to 
prevent  nourishment  disturbances  by  properly  dosing 
the  food. 

Drugs  should  never  be  given  in  the  form  of  tonics,  and 
should  only  be  used  when  acute  conditions  absolutely 
demand  them. 


CHAPTER  XXn 
INFANT   FEEDING   IN    RICKETS 

In  spite  of  the  fact  that  the  clinical  picture  of  rickets  is 
very  clearly  marked  and  that  the  condition  is  such  a  com- 
mon one,  there  has  never  been  a  satisfactory  explanation 
of  its  cause.  Is  it,  like  the  exudative  diathesis,  the  spasmo- 
phiUc  diathesis,  and  the  neuropathic  taint,  a  predisposi- 
tion which  develops  its  active  symptoms  only  under  ad- 
verse conditions,  or  is  it  the  result  of  some  product  of  meta- 
bolic or  bacterial  origin  which  acts  upon  an  organism  which 
from  the  standpoint  of  inheritance  is  normal?  Is  improper 
diet  the  cause  of  rickets,  or  does  it  only  influence  the  degree 
of  the  chnical  picture?  Five  possibilities  present  them- 
selves: first,  that  rickets  is  a  chronic  specific  bacterial  in- 
fection; second,  that  it  is  the  result  of  a  low-grade  chronic 
toxemia,  probably  caused  not  by  any  one  bacterium,  but 
by  a  number  of  various  infections;  third,  that  it  is  a  meta- 
bolic disturbance  due  to  the  excessive  or  deficient  absorp- 
tion of  certain  elements  of  the  food;  fourth,  that  it  is  the 
result  of  a  deficiency,  or  disturbance  in  secretion,  of  some 
one  or  more  of  the  ductless  glands  (suprarenal,  parathy- 
roid) ;  fifth,  that  it  is  due  to  some  inherited  predisposition 
which  is  distinctly  influenced  by  the  state  of  health  in 
extra-uterine  life. 

The  first  of  these  hypotheses  has  been  practically  aban- 
doned  by  modem  pathologists    and    pediatricians.    The 

268 


INFANT   FEEDING    IN    RICKETS  2G9 

second  is  sui)i)oi'ted  by  such  an  eminent  man  as  Marfan/ 
who  thinks  that  the  rachitic  bone  findings  and  otiier  patiio- 
logic  changes  can  best  be  explained  as  the  result  of  chronic 
intoxication,  whether  this  be  due  to  syphilis,  tuberculosis, 
or  gastro-intestinal  disturbances.  This  theory  is  supported 
by  the  work  of  lovanc  and  P'oitc,^  who  i)roduced  changes 
in  rabbits  almost  identical  to  those  of  rickets  by  injection 
of  alcoholic  and  acjueous  extracts  of  the  feces  of  rachitic 
infants  (with  and  without  gastro-intestinal  disturbances). 
Many  points  seem  to  favor  this  view,  but,  of  course,  dietetic 
errors  and  congenital  predisposition  cannot  be  discarded  as 
possible  factors  even  here.^ 

That  a  metabolic  disturbance  is  present  may  be  regarded 
as  proved,  but  that  this  disturbance  is  due  to  improper 
food  may  be  questioned.  It  is  a  veiy  noticeable  fact  that 
the  severest  forms  of  inanition  in  early  infancy  rarely 
show  distinct  rachitic  changes,  nor  do  they  develop  them 
later;  nor  is  there  a  greater  tendency  to  the  development  of 
rickets  in  these  children  than  in  normal  children  of  the  same 
age.  There  is  a  widespread  impression  in  America  that  if 
an  infant  be  fed  a  food  rich  in  fat  it  will  not  develop  rickets. 
From  a  clinical  standpoint  this  is  not  true,  nor  is  there  any 
scientific  reason  for  believing  that  it  should  be  true. 

Many  investigators  have  shown  that  there  is  a  deficiency 
of  calcium  in  the  system  in  cases  of  rickets.  Schabad*  has 
demonstrated  that  in  rachitic  infants  cod-liver  oil  promotes 
the  absorption  and  retention  of  calcium,  and  thus  its  well- 

1  Sem.  Med.,  1907,  xxvii,  469. 

2  La  Pediatria,  1907,  v,  641. 

'  For  a  complete  discussion  of  the  metabolism  of  rickets,  see  Orgler 
(Ergeb.  f.  inn.  Med.  u.  Kinderheilk.,  1912,  viii,  142)  and  Meyer  (Jahrb. 
f.  Kinderheilk.,  1913,  Ixxvii,  28). 

*  Jahrb.  f.  Kinderheilk.,  1910,  Lxxii,  1. 


270  INFANT   FEEDING 

known  beneficial  effects  are  explained.  On  the  other  hand, 
we  know  that  a  food  rich  in  fat  very  frequently  produces 
a  fat  constipation  in  which  calcium  is  withdrawn  from  the 
system.  The  action  of  cod-hver  oil,  therefore,  cannot  be 
generahzed  to  include  all  fats,  but  must  be  regarded  as  the 
property  of  that  form  of  food.  The  action  of  cod-hver  oil 
in  promoting  retention  of  calcium  is  markedly  increased 
by  the  addition  of  phsophorus  and  calcium  acetate  (Scha- 
bad).  There  is  no  parallehsm  between  the  severity  of  the 
rachitic  symptoms  and  that  of  the  nutritional  disturbance. 
Rickets  certainly  occurs  less  commonly  in  breast-fed  in- 
fants; so  it  is  fair  to  assume  that  there  is  a  relation  between 
rickets  and  the  character  of  the  food.  What  this  relation 
is  we  do  not  know,  further  than  to  state  that  overfeeding 
and  improper  feeding  distinctly  increase  the  degree  of  the 
rachitic  process.  As  yet  we  know  no  food,  not  even 
breast-milk,  which  will  insure  against  the  appearance  of 
rickets.  In  the  city  of  Chicago  in  the  last  few  years  the 
writer  has  seen  no  fewer  than  500  negro  babies  between  the 
ages  of  six  and  eighteen  months.  No  one  of  these  has  been 
free  from  rachitic  symptoms  and  bone  changes,  although 
many  showed  no  gastro-intestinal  symptoms  and  were  fed 
carefully  on  the  breast.  This  simple  fact  would  seem  to 
speak  strongly  against  the  theory  that  rickets  is  caused  by 
poor  feeding. 

The  theory  of  Stoltzner,*  that  rickets  is  caused  by  a 
deficiency  in  suprarenal  secretion,  has  found  few  adherents 
and  is  lacking  in  substantiation  by  facts.  The  effect  on 
the  gnawing  teeth  of  rats  by  removal  of  the  parathyroid 
gland  has  been  shown  by  Erdheim,^  and  is  suggestive,  as 

1  Pathologie  und  Therapie  der  Rachitis,  Berlin,  1904. 

2  Mitt.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1906,  xvi,  632. 


Fig.  2S. — Severe  rickets,  showinp:  marked  thoracic  deformity. 


INFANT   FEEDING    IN    RICKETS  271 

are  the  metabolic  experiments  demonstrating  the  increase^! 
excretion  of  calcium  in  parathyroidectomized  dogs  (Mac- 
Callum  and  Voegtlin).' 

In  support  of  the  theory  of  congenital  predisposition,  it 
may  be  said  that  the  occurrence  of  rickets  in  children  raised 
under  normal  conditions  suggests  that  there  must  be  some- 
thing more  than  acquired  disturbances  to  account  for  this. 
There  is  some  question  whether  rachitic  symptoms  are  pres- 
ent at  birth  or  not.  Kassowitz^  brings  much  support  to 
his  theory  of  congenital  rickets  by  his  recent  examinations 
on  newborn  infants,  but  as  to  whether  or  not  one  regards 
this  evidence  as  conclusive  can  in  no  way  affect  the  status 
of  a  congenital  predisposition. 

In  a  physical  way  rickets  influences  the  action  of  the  stom- 
ach and  intestines  by  producing  an  atonic  condition  of  the 
intestinal  musculature.  This,  in  turn,  produces  a  marked 
tendency  toward  constipation.  Marked  deformities  of  the 
chest  compress  the  lungs,  so  that  the  oxygen  supply  to  the 
tissue  is  insufficient  and  a  deficient  nutrition  develops. 
Such  extreme  deformities  are  not  common. 

Dietetic  Treatment  of  Rickets. — Though  one  can  offer  no 
assurance  that  rickets  will  not  develop,  no  matter  how  care- 
fully or  under  what  conditions  the  infant  may  be  brought  up, 
still  there  is  no  question  but  that  by  careful  attention  to 
the  rules  of  feeding  and  hygiene  a  severe  rickets  can  almost 
invariably  be  prevented.  There  is  no  indication  to  give  a 
food  rich  in  fat  in  order  to  prevent  the  appearance  nor  to 
alter  the  course  of  rickets,  but  each  child  should  be  studied 
as  to  his  individual  needs  and  fed  accordingly. 

1  Jour.  Exp.  Med.,  1909,  xi,  118. 

2  Jahrb.  f .  Kinderheilk.,  1912,  Ixxvi,  369. 


272  INFANT    FEEDING 

After  rickets  has  developed,  the  same  attention  to  the 
individual  case  must  be  observed.  In  addition,  cod-liver 
oil  (in  the  form  of  an  emulsion  or  plain)  should  be  given. 
In  giving  this,  one  should  be  careful  not  to  give  too  much 
and  not  to  give  it  at  all  in  hot  weather.  In  autumn,  winter, 
and  spring  one  should  never  give  over  1  teaspoonful  three 
times  a  day,  while  during  the  cooler  days  in  summer  a 
teaspoonful  morning  and  evening  is  usually  all  that  can  be 
given  with  advantage.  One  should  always  remember  that 
cod-liver  oil  is  a  food,  and  must  be  reckoned  with  in  es- 
timating the  total  food  value.  To  the  cod-liver  oil  it  is  weU 
to  add  phosphorus  to  the  amount  of  yfct  grain  to  the  dram 
dose  (ol.  morrh.,  100;  phosphori,  0.01). 


CHAPTER  XXIII 

INFANTILE    SCURVY 

Scurvy  (Barlow's  disease)  is  a  rather  uncommon  affec- 
tion, which  is  seen  more  frequently  among  the  middle  and 
wealthier  classes.  Its  pathology  consists  in  a  marked  tend- 
ency to  hemorrhage,  which  is  most  frequently  found 
primarily  beneath  the  periosteum  of  the  long  bones.  The 
bone  portions  most  affected  are  the  lower  end  of  the  femur 
and  upper  end  of  the  tibia.  These  give  the  characteristic 
tenderness  on  pressure  and  the  condition  peculiar  to  this 
disease,  in  which  the  child  is  happy  when  allowed  to  lie 
still,  but  cries  when  moved.  If  the  teeth  have  pierced  the 
gums  there  are  frequently  small  hemorrhagic  pouches  about 
their  bases. 

Arguing  more  from  analogy  than  from  any  true  scientific 
facts,  the  infantile  scurvy,  like  the  adult,  has  been  ascribed 
to  denaturized  food,  and  when  many  cases  are  tabulated 
it  is  seen  that  the  majority  have  been  fed  on  boiled 
milk,  condensed  milk,  malted  milk,  etc.  WTiether  this 
proportion  is  greater  than  is  that  of  other  artificially  fed 
babies,  one  must  seriously  question.  There  still  remain 
unaccounted  for  those  infants  whose  food  has  not  been  de- 
naturized. Recently  Hart  and  Lessing^  have  been  able  to  pro- 
duce scorbutic  lesions  in  monkeys  by  feeding  condensed  milk. 

In  connection  with  infantile  scurvy  the  metabolic  findings 

1  Der  Skorbut  der  kleinen  Kinder,  Stuttgart,  1913. 
18  273 


274  INFANT  FEEDING 

of  Lust  and  Klochmaiiiii  are  exceedingly  interesting.  They 
found  no  variation  in  the  nitrogen  metaboUsm  from  normal 
during  the  florid  stage;  there  was,  however,  greater  reten- 
tion of  calcium  phosphorus  and  chlorin  than  in  the  normal 
infant,  while  during  the  stage  of  convalescence  there  was  a 
negative  balance  of  these  salts  which,  after  some  weeks,  came 
back  to  normal. 

Treatment. — ^To  prevent  this  disease  would  probably  be 
very  easy  in  most  cases  if  we  knew  that  there  was  a  tendency 
to  scurvy,  but  since  it  is  obviously  impractical  to  order 
orange- juice  for  all  babies,  and  there  is  some  doubt  as  to 
the  advisabiUty  of  so  doing,  prophylaxis  is  a  rather  difficult 
matter.  The  response  to  treatment  is  so  immediate  in 
most  cases  that  it  is  also  rather  unnecessary. 

Active  treatment  consists,  in  the  younger  infants,  in  the 
administration  of  orange-juice.  This  is  best  given  between 
feedings,  to  the  amount  of  about  2  to  3  ounces  a  day.  In 
older  children  orange- juice  may  be  given  in  the  same  amount, 
or  baked  potato,  about  4  to  6  level  tablespoonfuls  a  day. 

The  results  from  this  treatment  are  very  rapid.  In  the 
case  of  medium  severity,  four  days  is  usually  sufficient  for 
the  disappearance  of  aU  symptoms,  while  in  very  severe 
cases  as  long  as  two  to  three  weeks  is  necessary. 

The  diet  should  be  changed,  if  the  child  is  on  denaturized 
food,  to  a  suitable  mixture  for  the  given  case.  If  the  food 
has  not  been  boiled,  evaporated,  etc.,  and  no  gastro-intes- 
tinal  symptoms  have  developed,  it  is  unnecessary  to  change 
it  at  all. 

During  the  first  weeks  after  the  disappearance  of  the 
symptoms  it  is  well  to  give  as  much  as  J  ounce  of  orange- 
juice  daily. 

1  Jahrb.  f.  Kinderheilk.,  1912,  Ixxv,  663. 


CHAPTER  XXIV 

INFANT    FEEDING    IN    ECZEMA 

In  the  infant  we  see  two  distinct  types  of  eczema:  the 
moist  eczema,  which'  occurs  nearly  exclusively  in  fat, 
flabby,  pale  infants;  and  the  dry  eczema,  which  is  found 
with  almost  the  same  regularity,  only  in  thin,  marantic 
infants. 

The  former  of  these  is  intimately  associated,  as  a  rule, 
with  other  signs  of  exudative  diathesis.  It  is  usually 
most  marked  on  the  cheeks  and  is  often  accompanied  by  a 
seborrheic  eczema  of  the  scalp.  The  dry  eczema  is  most 
likely  to  be  found  about  the  front  of  the  thorax  and  over 
the  shoulders. 

Concerning  metabolism  in  these  cases  little  is  known. 
Aschenheim^  has  shown  that  the  assimilation  boundary  for 
sugar  (especially  maltose)  is  low,  and  that  food  rich  in 
carbohydrates  often  leads  to  the  appearance  of  sugar  in  the 
urine.  Freund-  has  shown  a  marked  tendency  to  water 
retention. 

From  these  findings  we  would  conclude  that  the  carbo- 
hydrate (especially  maltose)  was  that  food-stuff  which 
should  be  eliminated  from  the  food  if  we  wish  to  get  the 
best  results,  both  because  of  the  apparent  inability  of  these 

^  Discussion  in  Monatsschr.  f.  Kinderheilk.,  1909,  viii,  425. 
'^  Cited  by  Moro,  von  Peer's  Lchrbuch  der  Kinderheilk.,  Jena,  1911, 
699. 

275 


276  INFANT   FEEDING 

infants  properly  to  assimilate  this  and  because  of  the  known 
tendency  of  carbohydrates  in  general,  and  sugars  in  par- 
ticular, to  promote  water  retention. 

Clinically,  the  removal  of  water  from  the  system,  as,  for 
instance,  by  a  severe  diarrhea,  is  immediately  followed  by 
a  distinct  improvement  of  the  eczema. 

Although  all  metaboHc  data  up  to  the  present  time  point 
to  the  fact  that  the  carbohydrates  are  disturbing  in  cases 
of  eczema,  clinical  experience  runs  distinctly  counter  to 
this,  and  shows  that,  while  the  starches  are  taken  care  of 
with  advantage,  it  is  the  fat  which  is  the  chief  source  of 
difficulty  and  the  amount  of  which  must  be  carefully  dosed. 

Treatment. — The  treatment  of  infantile  eczema,  with  the 
exception  of  local  protective  applications,  must  depend  al- 
most entirely  for  its  success  in  proper  regulation  of  the 
diet. 

In  the  breast-fed  infant,  if  lengthening  of  the  interval 
between  nursings  to  four  hours  and  temporary  shortening 
of  the  time  at  the  breast  are  not  sufficient,  it  is  necessary 
to  substitute  for  one  breast  nursing  a  feeding  of  carbohy- 
drate, usually  some  starchy  food  like  oatmeal,  barley,  or 
some  other  cereal,  sweetened  with  a  little  milk-  or  malt- 
sugar.  It  is  necessary  to  continue  this  treatment  for  some 
weeks  or  months  if  any  permanent  results  are  to  be  obtained. 
The  eczematous  condition  may  show  improvement  within 
a  few  days,  but  it  is  usually  many  weeks  before  anything 
resembling  a  cure  is  obtained. 

In  the  artificially  fed  baby  we  must  distinguish  in  our 
treatment  between  the  fat,  flabby,  overfed  infant  and  the 
poor,  puny,  marantic  child.  In  the  former  the  error  in 
diet  has  nearly  always  been  a  food  too  rich  in  fat.     The 


INFANT    FEEDING    IN    ECZEMA  277 

indication  for  treatment  in  these  cases  is  clear — reduction 
of  the  fat  and  substitution  of  carbohydrates.  On  the  other 
hand,  we  must  be  careful  not  to  give  a  fat-free  food  over 
too  long  a  time,  because  the  condition  of  starch  overfeeding 
is  much  more  to  be  dreaded.  If  we  must  decide  in  a  chronic 
case  between  a  moderate  amount  of  fat  in  the  food  with 
eczema  and  a  fat-free  food  without  eczema,  we  must  always 
choose  the  former.  For  since  the  eczema  in  itself  is  only 
an  annoying,  but  not  a  serious,  disease,  we  must  pay  atten- 
tion first  to  the  general  health  of  the  child  and  only  second- 
arily to  the  eczema. 

Finkelstein^  advises  the  use  of  a  food  prepared  in  the 
following  way :  To  1  liter  (quart)  of  milk  is  added  1  teaspoon- 
ful  of  pegnin  (a  rennet  ferment),  the  whole  heated  to  42°  C. 
(107.6°F.),  and  kept  at  that  temperature  for  one-half  hour. 
The  coagulum  is  then  separated  from  the  whey  and  made 
into  a  ball.  This  is  allowed  to  drain  through  a  linen  sack 
until  it  is  free  from  every  drop  of  whey.  The  whole  is  then 
finely  divided,  200  c.c.  (about  7  ounces)  of  whey  are  added, 
and  the  whole  put  through  a  sieve  mth  barley-water  sweet- 
ened with  1  tablespoonful  of  sugar,  the  whole  being  made 
up  to  1  liter  (quart).  This  mixture  is  not  to  be  used  in 
infants  under  one  year,  emaciated  infants,  nor  those  suffer- 
ing from  nutritional  disturbances.  The  writer  has  had  no 
experience  with  this  preparation. 

In  those  cases  of  chronic  malnutrition  complicated  by  a 
dry  scaling  eczema,  it  is  dangerous  to  attempt  any  measures 
directed  against  the  eczema  unless  full  account  is  taken 
of  the  general  condition  of  the  infant.  Most  of  these  cases 
require  that  our  efforts  be  directed  toward  the  general 
1  Med.  Klin.,  1907,  ii,  1098. 


278  INFANT   FEEDING 

nutrition.     It  not  infrequently  happens  that  if  this  can  be 
brought  up  to  normal  the  eczema  will  disappear. 

One  should  never  be  too  sanguine  as  to  the  results  to  be 
obtained  with  any  treatment  in  infantile  eczema.  There 
is  httle  question  but  that  regulation  of  the  diet  offers  the 
best  opportunity,  and  this,  if  carefully  managed  and  per- 
severed in,  win  eventually  bring  excellent  results. 


CHAPTER  XXV 

CONGENITAL  PYLORIC  STENOSIS  AND  PYLOROSPASM 

These  two  conditions  are  so  distinctly  associated  in  a 
clinical  way  that  it  is  necessary  to  consider  them  together. 
The  congenital  pyloric  stenosis  is  a  thickening  of  the  mus- 
cular coat  of  the  pylorus;  the  pylorospasm,  as  the  name 
implies,  is  a  state  of  spasm  of  the  pylorus.  Both  are  char- 
acterized by  uncontrollable  vomiting  and  by  appearance  of 
reverse  stomach  peristalsis  in  the  epigastrium. 

Etiology. — Primarily,  the  question  to  be  settled  is  as  to 
whether  either  or  both  of  these  conditions  are  congenital  in 
origin.  The  true  pyloric  tumor  has  once  been  found  post- 
mortem in  the  fetus  (Dent).*  It  is  hard  to  conceive  of  the 
formation  of  such  a  mass  in  the  first  two  weeks  of  life,  and  if, 
as  some  think,  the  condition  is  due  to  spasm  of  the  pylorus, 
.then  one  would  certainly  expect  to  find  a  tumor  present  in 
all  cases  of  pylorospasm.  The  mere  hypertrophy  of  the 
pylorus  does  not  mean  in  itself  stenosis.  It  is  possible  that 
this  hypertrophy  exists  at  birth,  and  that  the  normal  stom- 
ach secretions  and  contents  cause  in  such  an  hypertrophied 
muscle  a  distinct  overaction,  the  severity  and  extent  of 
which  varies  in  different  cases  and  requires  a  different  length 
of  time  to  develop.  This  would  explain  the  fact  that  some 
cases  manifest  themselves  almost  immediately  after  birth, 
while  others  appear  later. 

'  Quoted  by  Miller.     (See  later.) 

279 


280  INFANT   FEEDING 

At  present,  evidence  points  strongly  to  a  separation  of  this 
clinical  picture  into  two  separate  groups :  the  first,  congenital 
in  origin  and  characterized  by  a  distinct  hypertrophy  of  the 
pyloric  musculature;  the  second,  acquired  and  character- 
ized by  spasm  of  the  pylorus.  Whether  pylorospasm  is  a 
congenital  or  acquired  tendency  is  an  open  question. 
Most  cases  can  certainly  be  regarded  as  acquired,  since  the 
symptoms  do  not  manifest  themselves  until  several  weeks 
after  birth.  I  have  in  mind  one  case,  however,  in  which 
severe  vomiting  had  existed  every  day  without  interrup- 
tion from  birth  on,  which  on  operation,  at  the  end  of  the 
fourth  month,  showed  no  enlargement  at  the  pylorus. 

Both  conditions  are  most  often  encountered  in  the  first 
weeks  of  life.  The  stenosis  usually  appears  before  the  sixth 
week.  Most  of  the  infants  have  been  fed  previous  to  the 
disturbance  on  mother's  milk.  It  is  not  at  all  improbable 
that  nutritional  disturbances  may  play  some  part  in  cases 
of  pylorospasm.  Pyloric  stenosis  is  more  frequent  in 
males  and  in  the  first  bom. 

Pathology. — On  opening  the  abdomen  the  stomach  is 
usually  found  dilated;  if  contracted,  the  wall  is  thickened. 
If  stenosis  be  present  the  pylorus  is  found  of  cartilaginous 
hardness  and  very  much  hypertrophied.  Pfaundler^  has 
called  attention  to  the  fact  that  in  the  "  systoHc  "  stomach 
the  pylorus  may  be  as  large  in  circumference  as  in  some  cases 
of  pyloric  stenosis,  but  that  in  the  latter  the  mass  is  more 
elongated  and  does  not  disappear  when  50  to  60  c.c.  of 
water  is  introduced  into  the  cardiac  orifice.  Miller^  states 
that  sometimes  the  pylorus  is  found  tucked  in  behind  the 

1  Jahrb.  f.  Kinderheilk.,  1909,  Ixx,  253. 

2  The  Medical  Diseases  of  Children,  Bristol,  England,  1911,  260. 


CONGENITAL   PYLORIC   STENOSIS   AND    PYLOROSPASM     281 

pyloric  portion  of  the  stomach.  The  thickening  of  the 
pylorus  tapers  off  more  or  less  gradually  on  the  stomach 
side,  but  ends  abruptly  on  the  duodenal  side.  On  cutting 
through  the  pylorus  the  thickening  is  seen  to  be  wholly  in 
the  circular  fibers  of  the  musculature,  while  the  mucous 
membrane  lies  in  deeper  folds  than  is  normally  the  case. 
Microscopically,  there  is  seen  only  hypertrophy  of  the  cir- 
cular muscular  coat  of  the  pylorus. 

The  duodenum  is  white  and  collapsed  in  the  advanced 
cases,  and  is  so  atrophic  that  it  is  frequently  unable  to  per- 
form its  proper  function  after  communication  between  it  and 
the  stomach  is  established.  Some  unimportant  congenital 
anomalies  of  other  parts  of  the  body  have  been  found. 

Sjrmptoms. — These  usually  begin  very  early  in  life,  often 
before  two  weeks,  and  rarely  after  three  months.  The  ex- 
cessive uncontrollable  vomiting  and  the  constipation  soon 
lead  to  extreme  emaciation  and  frequently  to  death  from 
starvation. 

The  vomiting  is  the  most  characteristic  symptom,  and 
yet  in  itself  there  is  little  that  is  distinctive  except  its  per- 
sistence. It  may  be  ordinary  vomiting  or  it  may  be,  and 
frequently  is,  projectile  in  type.  It  is  never  a  simple 
regurgitation.  It  occurs  more  frequently  a  few  minutes 
(fifteen  to  thirty)  after  taking  food,  but  may  not  occur  for 
several  hours.  The  amount  vomited  is  often  more  than 
that  ingested.  It  matters  very  little  what  the  nature  of 
the  ingested  food  maj^  be:  even  water  is  immediately  vom- 
ited in  the  severest  cases.  As  one  would  expect  from  the 
nature  of  the  disease,  the  vomitus  is  never  bile-stained  nor 
fecal.  Rumination  is  sometimes  seen  in  pylorospasm 
(Aschenheim).^ 

^Zeitschr.  f.  Kinderheilk.,  1913,  viii,  161. 


282  INFANT   FEEDING 

The  stool  is  very  small  and  ribbon-like,  but  usually  well 
digested.  It  is  passed  infrequently,  once  in  twenty-four 
or  forty-eight  hours. 

Subjective  nervous  symptoms  are  lacking.  The  children 
are  usually  contented,  considering  their  general  condition. 
Sometimes  during  intense  peristaltic  action  there  seems  to 
be  some  discomfort.     The  urine  is  scanty. 

Physical  Signs. — ^When  first  seen  these  infants  are 
emaciated  and  pale.  In  the  more  advanced  cases  a  slight 
cyanosis  is  seen.  They  do  not  have  the  "  sick  "  appearance 
of  infants  suffering  with  severe  nutritional  disturbances  nor 
do  they  seem  so  discontented.  Of  course,  they  are  weak 
and  relaxed. 

The  physical  signs  of  importance  are  those  of  the  epigas- 
tric region.  Gastric  peristalsis  is  very  active.  The  stom- 
ach is  seen  to  bulge  just  beneath  the  costal  arch,  the  peris- 
taltic waves  become  gradually  more  and  more  manifest; 
finally,  the  stomach  seems  to  assume  a  sort  of  hour-glass 
shape  with  a  marked  constriction  in  the  middle.  This 
constriction  draws  closer  and  closer  to  the  pyloric  extremity 
and  then  retreats,  showing  the  antiperistalsis,  which  is  often 
followed  by  an  explosive  attack  of  vomiting.  One  should 
not  expect  to  see  this  whenever  the  child  is  examined.  It 
usually  requires  constant  watching  over  at  least  a  half- 
hour  (frequently  much  longer)  to  get  the  typic  peristaltic 
action.  When  the  typic  peristalsis  is  seen,  there  is  no 
question  of  the  presence  of  a  hindrance  to  the  passage  of 
food  from  the  stomach  into  the  duodenum.  No  diagnosis 
of  any  such  hindrance  can  be  positively  made  unless  the 
typic  peristalsis  is  present  in  the  epigastrium. 

The  next  important  physical  sign  is  the  palpation  of  a 


4 


J 


4 

^ 


J 


Fip.  29.— Pyloric  stenosis  (Hirhter  and  Walls). 


CONGENITAL   PYLORIC  STENOSIS   AND    PYLOR08PA8M     283 

tumor  in  the  region  of  the  pylorus.  If  present,  this  is  felt 
up  under  the  liver  just  to  the  right  of  the  median  Une.  It 
gives  the  sensation  which  one  has  on  feeling  a  rather 
deeply  situated  enlarged  lymphatic  gland,  but  the  mass  is, 
of  course,  harder  to  determine  accurately  and  somewhat 
more  movable.  It  seems  to  be  about  the  size  of  a  marble 
and  is  of  rather  hard  consistency.  The  pyloric  tumor,  even 
if  present,  is  not  by  any  means  always  palpable.  Perhaps 
in  a  certain  number  of  cases  this  may  be  due  to  the  po.sterior 
position  of  the  pylorus  as  described  by  Miller.  Its  pres- 
ence is  almost  absolute  evidence,  together  with  the  gavStric 
peristalsis,  of  an  existing  hypertrophic  pyloric  stenosis, 
but,  on  the  other  hand,  failure  to  palpate  such  a  mass  does 
not  necessarily  mean  that  a  hypertrophied  pylorus  is  not 
present. 

As  to  the  chemical  reaction  in  the  gastric  contents,  many 
conflicting  reports  have  been  forthcoming,  mostly  because 
there  has  been  no  sharp  distinction  possible  between  pylo- 
rospasm  and  hypertophic  pyloric  stenosis.  It  is  certain 
that  in  a  large  proportion  of  the  cases  no  change  from 
normal  has  been  noted,  and  that  those  cases  which  give  the 
slightest  physical  signs  usually  give  the  most  marked  in- 
crease in  acidity.  Clark^  found  in  pylorospasm  two  classes 
of  cases — those  with  hyperacidity  and  those  with  hypo- 
acidity. His  results  are  especially  reliable,  since  they  were 
always  carried  out  under  the  same  conditions  as  to  fluid 
used,  time  after  ingestion,  etc.  Hess-  found  in  most  of  his 
cases  a  profuse  pancreatic  secretion  which  contained  an 
average  amount  of  ferment. 

1  Arch.  Ped.,  1911,  xxviii,  648. 

*  Amer.  Jour.  Dia.  of  CMld.,  1912,  iv,  205. 


284  INFANT   FEEDING 

Diagnosis. — ^The  diagnosis  is  based  upon  the  uncontrolla- 
ble vomiting,  the  gastric  peristalsis,  and  the  palpable  pyloric 
tumor.  Continued  vomiting  without  diarrhea  in  a  young 
breast-fed  infant,  the  interval  between  feedings  being  four 
hours,  is  very  suggestive.  This  is  more  so  if  the  infant 
vomits  the  water  given  between  feedings.  Such  a  history, 
coupled  with  emaciation,  should  lead  one  to  investigate 
carefully  the  cause. 

Diagnosis  of  these  conditions  can  only  be  made  if  the 
peristaltic  action  of  the  stomach,  as  above  described,  is  seen. 
Pylorospasm  may  exist  without  the  presence  of  this  peris- 
talsis, but  its  presence  can  only  be  conjectured.  This 
phenomenon  will  distinguish  the  condition  from  other  forms 
of  vomiting.  It  should,  therefore,  always  be  looked  for  if 
the  vomiting  is  severe  and  continuous. 

As  to  the  cause  of  the  pyloric  constriction,  it  is  more 
difficult  to  determine.  Not  only  spasm  and  congenital 
hypertrophy  can  act  in  this  manner,  but  also  perigastric 
adhesions  due  to  fetal  peritonitis  (Grulee  and  Kelly). ^ 
It  is  impossible  to  differentiate  these  conditions  from  a  prac- 
tical standpoint  unless  the  presence  of  a  congenital  hyper- 
trophy is  made  certain  by  the  palpation  of  a  tumor. 

We  should  be  careful  not  to  misinterpret  the  abdominal 
findings.  I  have  seen  distinct  peristalsis  in  a  very  transient 
attack  of  vomiting  in  a  young,  emaciated  infant.  The 
peristalsis,  however,  was  not  of  the  violent  type  found  in 
pyloric  stenosis,  nor  was  there  any  antiperistalsis.  This 
experience  agrees  with  that  of  Hoffa.^    Hess^  is  inclined  to 


1  Surg.,  Gyn.,  and  Obst.,  1910,  x,  402. 

2  Monatsschr.  f.  Kinderheilk.,  1912,  x,  533. 

3  Reported  before  the  Chicago  Pediatric  Society,  Dec.  16,  1913. 


CONGENITAL   PYLORIC   STENOSIS   AND   PYLOROSPASM     285 

put  less  stress  on  visible  gastric  peristalsis  and  more  on  tlie 
state  of  the  pylorus,  as  shown  by  the  duodenal  catheter. 
Whether  spusmopiiilia  can  affect  the  unstriated  muscle  and 
produce  symptoms  closely  resembling  pyloric  stenosis  is  a 
question  yet  to  be  solved.  I  have  had  1  case  under  my  care 
which  strongly  suggested  such  a  possibility. 

Prognosis. — This  depends  upon  three  conditions:  First, 
the  duration  of  the  condition  before  treatment  is  begun; 
second,  the  nature  of  the  underlying  condition;  third,  the 
method  of  treatment.  Very  little  dependence  can  be  put  on 
statistics,  since  there  is  such  a  wide  variance  in  the  opinion 
as  to  what  constitutes  pylorospasm  and  as  to  whether 
we  can  diagnose  it  without  finding  the  gastric  peristalsis. 
We,  therefore,  can  form  no  definite  opinion  of  those  cases 
which  have  been  treated  by  means  other  than  operative. 
Practically  all  cases  subjected  to  operation  and  reported 
have  been  so  treated  for  congenital  hypertrophy.  Ibrahim' 
collected  136  operated  cases,  with  a  mortality  of  55.1  per 
cent.  Subsequent  to  this  the  writer^  has  been  able  to  find 
reports  of  20  cases  with  6  deaths,  a  total  of  156  cases  with  82 
deaths,  a  mortality  of  52.6  per  cent.  In  striking  contrast 
to  this  general  mortality  stand  out  such  reports  as  those  of 
Walls,^  of  8  cases  with  1  death.  The  prognosis  of  the  in- 
dividual case  must  depend  as  much  upon  the  attending 
physician  and  surgeon  as  upon  the  condition  of  the  patient. 
The  judgment  of  one  and  the  skill  of  the  other  must  be  a 
large  factor  in  the  success  of  surgical  treatment. 

Treatment. — The   method  of  treatment  is  a  very  live 

1  Ergeb.  f.  inn.  Med.  u.  Kinderheilk.,  1908,  ii,  270. 

2  Surg.,  Gyn.,  and  Obst.,  1910,  x,  556. 

3  Illinois  Med.  Jour.,  1909,  xvi,  866. 


286  INFANT    FEEDING 

question  at  present.  American  writers  in  general  favor  the 
surgical  procedure,  while  German  pediatricians  are  as 
strong  in  their  belief  in  the  dietetic  treatment.  As  to  which 
of  these  is  to  be  preferred  the  future  must  decide.  The 
atrophic  condition  of  the  small  intestine  found  in  the  ad- 
vanced cases  certainly  speaks  against  delaying  operation 
too  long,  and  against  final  success  in  an  obstinate  case 
treated  by  dietetic  measures. 

Surgical  Treatment. — Although  many  different  operations 
have  been  employed  up  to  the  present  time,  that  which  has 
given  the  best  results  is  posterior  gastro-enterostomy.  It 
is  absolutely  necessary  in  these  cases  that  a  skilled  surgeon 
be  employed  and  that  the  operation  be  done  in  the  shortest 
time  possible.     Ether  is  the  best  anesthetic. 

Postoperative  Treatment. — After  the  operation  it  is  often 
necessary  to  stimulate  with  strychnin  or  continuous  saline 
enema.  Water  should  not  be  given  for  from  four  to  six 
hours.  If  at  the  end  of  this  time  water  is  retained,  food 
in  the  form  of  teaspoonful  quantities  of  skimmed  (cows'  or 
mothers')  milk  should  be  given  as  often  as  every  two  hours. 
The  amount  can  be  increased  and  the  period  lengthened  as 
rapidly  as  the  infant's  condition  will  permit.  It  is  usually 
not  necessary  to  keep  the  amount  of  food  reduced  for  a  long 
time,  because  when  improvement  once  begins  it  is,  as  a 
rule,  rapid.  Vomiting  usually  continues  for  several  days 
following  operation,  but  is  not  violent  in  character  and  is 
suggestive  rather  of  stomach  irritation  than  of  obstruction. 

Dietetic  Treatment. — Ideas  as  to  the  proper  dietetic 
measures  to  be  taken  in  these  cases  are  very  different. 
Heubner  employs  long  intervals,  with  relatively  large 
amounts  of  food,  while  Ibrahim  gives  small  amounts  at 


CONGENITAL   PYLORIC   STENOSIS   AND   PYLOROSPASM    287 

short  intervals.  Feer  advises  the  use  of  skimmed  breast- 
milk.  It  seems  to  the  writer  that  if  the  diet  is  to  be  relied 
on,  small  amounts  of  food  poor  in  fat  ^ven  at  long  intervals 
should  first  be  tried,  and  after  that  the  amount  increased, 
together  with  increase  in  the  fat-content. 

Medicinal  and  Other  Measures. — Gastric  lavage  is  of  much 
use  in  these  cases,  and  should  be  often  repeated  if  the  in- 
fant is  not  in  too  weakened  a  condition.  Small  doses  of 
bromids  may  be  given  to  quiet  the  general  unrest  and,  to  a 
degree,  the  peristaltic  action.  Opiates  may  be  used  in  the 
same  way,  but  vAth  more  caution.  Rosenstern^  advises 
rectal  enemas  of  sodium  chlorid,  7.5  gm.  (2  drams);  po- 
tassium chlorid,  0.42  (3  grains);  calcium  chlorid,  0.24  (1^ 
grains);  water  1000  c.c.  (1  quart).  In  cases  of  hj'peracidity 
this  has  been  shown  to  decrease  the  amount  of  acid  in  the 
stomach.  Sodium  citrate  has  never  given  satisfactory 
results.  Cowie-  ad\'ises  the  use  of  antacids,  pro\'ided  their 
dosage  is  according  to  the  amount  of  free  acid  in  the  stomach 
contents.  Too  much  alkali,  according  to  Co\^■ie,  closes 
rather  than  opens  the  pylorus. 

From  the  indefiniteness  of  these  instructions  it  will 
readily  be  seen  that  no  measure,  either  dietetic  or  medicinal, 
has  been  sufficiently  successful  to  meet  with  universal  apH 
proval,  and  it  is,  therefore,  fair  to  assume  that  the  results 
are  obtained  not  by  the  method  employed,  but  by  the  judg- 
ment of  the  physician  in  the  individual  case.  Overfeeding 
must  be  carefully  avoided  because  it  will  only  tend  to 
exaggerate  the  condition.  At  the  same  time  it  is  very  diffi- 
cult to  make  these  infants  retain  sufficient  quantities  to 
preserve  life. 

'  Deutsch.  Med.  Wochenschr.,  1010,  xxxvi,  31. 
«  Amer.  Jour.  Dis.  of  Child.,  1913,  v,  225. 


CHAPTER  XXVI 
INFANT   FEEDING   IN    OTHER   DISEASES 

Acute  Infectious  Diseases. — There  are  no  special  rules 
in  regard  to  the  diet  in  this  class  of  diseases.  A  simple 
reduction  in  the  amount  of  food  during  the  febrile  period 
and  the  eariy  part  of  convalescence  is  essential.  One  should 
always  remember  that  nutritional  disturbances  are  favored 
by  the  presence  of  these  acute  diseases  and  are  to  be  treated 
as  such.  Chief  among  these  is  intoxication.  It  is  very 
difficult  to  distinguish  this  from  the  disease  itself  in  many 
instances.  Diarrhea  is  frequently  a  symptom  of  the  dis- 
ease (as  in  typhoid  fever),  but  more  often  it  points  to  over- 
feeding. Vomiting  is  not  common  except  in  whooping- 
cough,  in  which  instance  much  benefit  can  be  derived  from 
gastric  lavage.  It  is  not  at  aU  improbable  that  the  mucus 
from  the  nasopharynx  when  swallowed  may  prove  irritating 
to  the  intestinal  tract,  and  that  for  this,  too,  lavage  is  of 
benefit.  When  a  hyperpyrexia  exists,  barley-water  alone 
should  be  given,  but  the  supply  of  water  should,  under  all 
circumstances,  be  kept  up. 

Tuberculosis. — In  the  miliar}^  tuberculosis  and  tubercular 
meningitis  dietetic  treatment  is  obviously  of  no  avail, 
nor  does  it  seem  possible  by  change  of  food  to  prevent  the 
occurrence  of  the  green  mucous  stool  which  is  so  frequently 
seen.    Langstein^  believes  that  he  has  lengthened  the  life 

1  Zeitschr.  f .  Kinderheilk.,  1913,  vii,  193. 

288 


INFANT   FEEDING    IN    OTHER    DISEASES  289 

of  his  cases  of  tuberculosis  in  infants  by  the  use  of  albumen- 
milk.  He  lays  stress  on  the  importance  of  giving  sufficient 
food,  and  believes  that  any  tendency  to  vomiting  will  be 
bettered  if  large  quantities  are  given  every  four  hours,  if 
necessary  by  gavage.  From  a  diagnostic  standpoint  one 
should  remember  that  miliary  tuberculosis  is  characteristic- 
ally accompanied  by  a  diarrhea  with  four  to  five  green  mucous 
stools  a  day,  and  that  this  is  in  no  way  dependent  on  the 
character  or  the  amount  of  food.  Here,  too,  nutritional  dis- 
turbances may  occur,  but  the  child  can  rarely  be  prevailed 
upon  to  take  enough  food  to  sustain  life,  hence  disturbances 
due  to  excessive  quantities  are  rare. 

Scrofulosis  is  usually  encountered  not  earher  than  the 
last  half  of  the  second  year.  Contrary  to  the  experience 
of  most  clinicians,  the  writer  has  had  the  best  results  in 
these  cases  with  a  carbohydrate-rich  diet.  He  never 
employs  cream  and  not  over  a  quart  of  milk  a  day.  The 
bulk  of  the  food  consists  of  vegetables  and  cereals.  Of 
course,  in  all  the  cases  the  diet  forms  only  part  of  the 
treatment. 

Congenital  Syphilis. — In  the  first  two  months  of  life  in 
cases  of  congenital  syphilis  which  have  remained  untreated 
there  is  often  present  a  diarrhea  with  or  without  vomiting. 
In  the  typic  uncomplicated  cases  there  is  no  change  of 
temperature  from  the  normal,  although  the  diarrhea  may 
reach  ten  to  thirteen  watery  stools  a  day.  The  stools  are 
green  and  watery,  as  a  rule  do  not  contain  mucus  and 
curds,  which,  if  present,  are  not  characteristic.  Without 
change  of  food  w^hcn  given  proper  antisyphilitic  treatment 
the  diarrhea  stops  in  two  to  four  days,  the  infant  begins 
to  gain  weight,  and  in  every  way  takes  on  the  appearance 

19 


290  INFANT   FEEDING 

and  actions  of  a  normal  child  of  the  same  age.  This 
diarrheal  condition  is  especially  noticeable  in  breast-fed 
infants,  but  is  by  no  means  confined  to  these,  and  should 
always  be  thought  of  in  cases  with  diarrhea  during  the 
first  year  of  Hfe,  but  more  especially  during  the  first  two 
months. 

In  all  cases  of  congenital  syphilis,  except  those  which  do 
not  respond  to  treatment  (mahgnant  forms,  syphilis  of  the 
central  nervous  system,  hydrocephalus,  etc.),  the  diet 
should  be  regulated  as  is  that  of  an  infant  under  hke 
nutritional  condition  without  syphilis.  Syphihs  in  itself, 
when  treated  properly  and  in  the  early  months  of  hfe,  does 
not  affect  the  general  nutritional  condition  to  a  noticeable 
degree.  The  same,  of  course,  cannot  be  said  of  neglected 
cases,  and  yet  in  these  the  results  of  treatment  are  very 
surprising.  There  is  no  specific  dietetic  treatment  for  con- 
genital syphilis,  nor  is  any  necessary.  The  general  rules 
for  diet  in  health  and  in  nutritional  disturbances  hold 
here  as  in  those  infants  not  suffering  with  congenital 
syphilis,  provided  always  that  proper  antisyphilitic  treat- 
ment is  effective.  An  apparent  exception  is  in  those  cases 
where  congenital  syphilis  has  caused  the  child  to  be  bom 
prematurely,  but  in  those  cases  it  is  likely  that  the  sjrphi- 
litic  infection  is  so  severe  that  it  cannot  be  overcome  by 
treatment,  which  condition  can  be  regarded  as  a  result  not 
of  the  lowering  of  the  infant's  tolerance  for  food,  so  much 
as  an  overwhelming  of  the  organism  with  the  syphilitic 
infection.  Cases  of  syphilitic  hydrocephalus  rarely  show 
the  proper  reaction  to  food  (i.  e.,  gain  in  weight,  etc.), 
because  of  the  cerebral  involvement,  and  because  on  these 
cases  treatment  has  little  or  no  effect.     But,  as  a  general 


INFANT   FEEDING    IN   OTHER   DI8EA8E8  291 

rule,  we  can  say  that  if  the  clinical  manifestations  of  con- 
genital syphilis  are  prevented  by  treatment,  the  problem  of 
diet  is  no  more  difficult  in  the  syphilitic  than  in  the  non- 
syphilitic  infant. 

In  congenital  heart  disease,  duo  to  the  lack  of  projjcr 
oxygenation  of  the  blood  in  this  condition,  with  the  con- 
sequent deficient  supply  of  oxygen  to  the  tissues,  there  is 
usually  seen  a  distinct  state  of  malnutrition.  This  is  not 
to  be  influenced  by  change  in  diet  nor  by  any  other  means 
at  our  disposal.  One  must  always  be  careful  not  to  overfeed 
these  infants,  since  their  resistance  is  very  low,  and  even  a 
shght  disturbance  is  likely  to  prove  fatal. 

Anemia  infantum  psuedoleucaemica  is  not,  so  far  as  known, 
influenced  by  diet  changes.  The  weight^curve  is  steadily 
downward  until  death  occurs. 

Respiratory  Diseases. —  Nasopharyngitis  assumes  special 
importance  because  of  the  mucus  produced  and  swallowed. 
If  we  recognize  that  mucus  is  the  chief  medium  in  which  the 
putrefactive  bacteria  act,  we  can  see  how  this  may  produce 
nutritional  disturbance.  If  possible  the  stomach  should 
be  washed  frequently  where  the  amount  of  mucus  is  such  as 
to  cause  disorders.  I  have  seen  at  least  one  case  of  con- 
tinued vomiting  as  the  result  of  irritation  to  the  mucous 
membrane  of  the  stomach  from  this  source,  which  was 
greatly  relieved  by  gastric  lavage.  The  administration  of 
cod-liver  oil  in  small  doses  (^  to  1  dram  two  to  three  times 
a  day)  is  of  much  benefit  in  a  large  number  of  cases,  but  we 
must  be  very  careful  not  to  give  so  much  as  to  favor 
vomiting. 

In  bronchitis  cod-liver  oil  has  an  especially  good  eff"ect. 
The  total  amount  of  food  must  be  diminished  before  its 


292  INFANT   FEEDING 

administration  or  there  is  danger  of  nutritional  disturbance. 
During  convalescence  the  cod-liver  oil  should  be  continued 
and  the  value  of  the  food  gradually  increased.  It  is  the 
custom  of  the  writer  to  use  this  treatment  combined  with 
hygienic  measures  alone  in  cases  of  bronchitis  without  high 
fever. 

Bronchopneumonia  requires  a  rather  marked  reduction 
of  the  food.  Sometimes  in  this  condition  the  weight  tends 
to  increase  rather  than  diminish  during  the  active  stage, 
only  to  fall  rapidly  during  resolution.  This  is  due  not 
to  the  food,  but  to  the  accumulation  of  exudate  in  the 
lung.  In  the  subacute  wasting  types  either  breast-milk 
or  albumin-milk  offer  the  best  means  of  keeping  up  the 
resistance. 

Pyelocystitis. — In  the  early  stages,  when  proper  treat- 
ment is  given,  it  is  not  necessary  to  change  the  diet  further 
than  a  simple  temporary  reduction.  Where  the  condition 
has  existed  for  some  time  a  marantic  state  exists  which  is 
peculiarly  resistant  to  dietetic  measures.  Probably  the 
best  means  of  treatment  is  to  regard  this  condition  as  a 
severe  case  of  decomposition  on  which  is  superimposed  a 
pyelocystitis.  Treatment  for  the  latter  must  be  continued 
and  the  food  very  cautiously  dosed.  It  may  take  several 
weeks  or  months  in  the  more  severe  cases  to  bring  the  in- 
fant to  the  state  where  it  will  react  normally  to  food. 

Pyelocystitis  is  nearly  always  accompanied  by  diarrhea, 
and  for  this  reason  it  is  frequently  overlooked  and  the 
gastro-intestinal  symptoms  regarded  as  indicative  of  a 
severe  nutritional  disturbance.  The  urine  of  all  infants 
suffering  from  diarrhea  with  fever  should,  therefore,  be 
carefully  examined. 


INFANT   FEEDING    IN    OTHER   DISEASES  293 

Cretinism,  idiocy,  etc.,  require  no  special  diet.  On  the 
other  hand,  a  cretin  which  has  gone  some  time  without 
treatment  will  often  show  a  severe  degree  of  malnutrition, 
which  will  res[)on(I  to  thyroid  treatment  and  will  gain 
weight  rapidly  without  any  change  in  diet  whatever.  As 
to  idiocy,  little  can  be  said.  Some  idiots  are  remarkably 
well  nourished,  while  others  show  quite  severe  states  of 
malnutrition. 

Otitis  Media. — The  fever  requires  that  the  food  be  re- 
duced. After  paracentesis  the  fever  rapidly  falls,  and  the 
proper  food  for  the  normal  infant  under  the  same  conditions 
may  be  given.  Otitis  media  is  nearly  always  associated 
with  nasopharyngitis,  and,  therefore,  disturbance  from  the 
swallowing  of  mucus  may  occur. 

Funmculosis. — Aside  from  the  local  treatment,  the  diet 
in  these  cases  must  be  carefully  watched.  All  nutritional 
disturbances  should  be  avoided.  Large  amounts  of  fat 
or  sugar  in  the  food  seem  to  favor  continuation  of  the 
disease.  The  fat  in  most  cases  should  not  be  removed 
entirely,  because  of  its  favorable  effect  upon  resistance. 
In  furunculosis  the  state  of  the  nutrition  is  of  paramount 
importance,  and  every  means  must  be  employed  to  prevent 
the  occurrence  of  nutritional  disturbances  and  to  overcome 
such  as  exist.  No  special  suggestions  are  necessar}',  since 
the  disturbances  encountered  are  those  which  have  already 
been  treated  of  in  the  chapters  on  the  subject. 


INDEX 


Abscess  of  breast  in  breaat-nurs- 

ing,  86 
Absorption,  36 

and  metabolism,  36 
by  intestinal  mucosa  in  decom- 
position, 193 
of  cane-sugar,  42 
of  fat,  34,  41 
of  malt-sugar,  42 
of  phosphorus,  50 
Acacia,  113,  232,  235 
Acetone  in  urine,  40 

in  spasmophiUa,  260 
Acetozone,  231 
Acidity  of  stomach,  30 
Acidosis,  41,  52 
in  intoxication,  213 
in  weight  disturbance,  169,  172 
Acute  infectious  diseases,  225 

diarrhea  in,  288 
Adrenalin  eye-test  in  intoxication, 
218 
hydrochlorate  in  edema  of  in- 
toxication, 233 
Air,  swallowing  of,  in  gas  eructa- 
tion, 234 
Albumin,  36 
in  stools,  36 

in  urine  in  intoxication,  28 
Albumin-milk,  131 
caloric  value  of,  131 
composition  of,  131 
in  mixed  feeding,  96 
in    treatment    of    bronchopneu- 
monia, 292 
of  decomposition,  206 
of  dyspepsia,  187 
of  premature  infants,  250 


Albumin-milk  in  treatment  of  tu- 
berculosis, 289 
modifications  of,  131 
preparation  of,  130 

Albumin-water,  137 
in  intoxication,  229 

Alcohol,  207,  233 
in  breast-milk,  79 

Allen,  148 

Amberg,  40 

Amboceptors  in  breast-milk,  80 

Amino-acids,  33 

Ammonia,  39 

coefl&cient    in    protein    metabo- 
lism, 38,  39 

Ammonia-content  in  urine,  40,  169 
in  dyspepsia,  182 
in  intoxication,  213 

Ammoniacal  urine  in  dyspepsia  of 
breast-fed  infant,  108 

Amylopsin,  33 

Anatomy  of  the  gastro-intestinal 
tract,  21 

Anemia  infantvun  pseudoleukaem- 
ica,  291 

Anger,  violent  fits  of,  or  other  sud- 
den emotions  in  breast-nursing, 
86 

Antacids  in  congenital  pyloric  sten- 
osis, 287 

Anterior  pohomyehtis,  225 

Antiperistalsis,  282 

Antipyrin  in  breast-milk,  79 

Antiseptics,  intestinal,  in  meteor- 
ism,  239 

Antitoxic  bodies,  absorption  of,  34 

Apple,  258 
juice,  155 

295 


296 


INDEX 


Arrow-root  crackers,  155 

flour,    composition   and   caloric 

value  of,  133 
water,  128,  262 
Arsenic  in  breast-milk,  79 
Artificial  feeding,  116 
foods  used  in,  116 
for  normal  infant,  141,  146 
in  first  twenty-four  hours,  152 
in  ninth  month,  154 
in  remainder  of  first  week,  152 
in  tenth  month,  154 
malt-sugar  in,  149 
standards  of,  149 
starches  in,  149 
food  for  infant,  amoimt  of  fat  in, 
148 
of  milk-sugar  in,  149 
of  protein  in,  148 
preparation  of,  142 
Artificially    fed    infant,    etiologic 
classification     of     nutri- 
tional    disturbances     in, 
157 
nutritional  disturbances  of, 
156 
Aschenheim,  41,  189,  275,  281 
Ash  in  breast-milk,  77 
Ash-content  of  colostrum,  73 
Asthmatic    attacks    in    exudative 

diathesis,  255 
Atonic  intestinal  musculatvtre,  271 
Atrophy,  190 
Atropin  in  breast-milk,  79 

Babcock,  119,  120 
Bacillus  acidophilus,  58,  243 

biologic  characteristics  of,  56, 

57 
in  intoxication,  212 
in  small  intestine,  55 
bifidus  communis,  58 

biologic  characteristics  of,  55 
in  stool,  57,  58 
butjrric  acid,  motile,  in  small  in- 
testine, 55 


Bacillus  coli  communis,  33 

biologic    characteristics    of, 

56 
in  intoxication,  212 
in  mouth,  53 
dysentericus,  243 

(Flexner)  intoxication,  211 
lactis  aerogenes,  58,  121 

biologic    characteristics    of, 

56 
in  stool,  57,  58 
in  treatment  of  dyspepsia, 
189 
of  intoxication,  231 
mesentericus  in  small  intestine, 

55 
perfringens,  58 

biologic  characteristics  of,  56 
in  mouth,  53 
putrificus,  56 

in  small  intestine,  55 
pyocyaneus  in  intoxication,  212 
tubercle,  in  condensed  milk,  127 
Bacteria,    biologic    characteristics 
of,  55 
in  cows'  milk,  118 
in  mouth,  53 
in  small  intestine,  54 
in  stomach,  54 
in  stool,  57,  243 

specific  action  of  pathogenic,  in 
intoxication,  213 
Bacteriology    of    gastro-intestinaJ 

tract,  53 
Bahrdt,  39,  57,  78,  180 
Balanitis   in   exudative   diathesis, 

255 
Bamberg,  39,  83,  180 
Bands,  tight,  236 
Barley,  276 
Barley-flour,  134 

composition  and  caloric  value  of, 
133 
Barley-water,  111,  288 
in  intoxication,  227 
in  treatment  of  dyspepsia,  187 


INDEX 


297 


Barlow's  disease,  273 

Basch,  81 

Bath,  cold,  in  dyspepsia,  188 

in  intoxication,  231 
Bathing,  112 

in  decomposition,  207 

in  intoxication,  22G,  230 
Beck,  256 
Beef-extract,  138 
Beef-juice,  137 
Beets,  155,  258 

in  diarrhea,  241 
Bcifeld,  57 

Belladonna  in  breast-milk,  79 
Bendix,  49 
Benfey,  152,  256 
Berend,  48,  263 
BergeU,  76 
Bergmann,  49 
Biedert,  136 
Biedcrt's  food,  136 
Bile,  33 

capillaries,  26 

in  diarrhea,  241 
Bilirubin,  241 

Biliverdin  in  diarrheic  stool,  242 
Biologic  characteristics  of  bacteria, 

55 
Birk,  38,  39,  62,  73,  74,  129,  249 
Bismuth,  112,  113,  243 

in  breast-milk,  80 

in  diarrhea,  241 

in  dyspepsia,  189 

milk  of,  238 

subcarbonate,  232 

subnitrate,  232,  235 
Blood,  calcium  in,  47 

in  stool  in  diarrhea,  242 
Bluhdorn,  46 
Blum,  180 
Blythe,  139 

Body,  physiologic  effects  of  inor- 
ganic salts  on,  47 
Bones  in  normal  infant,  66 
Bottles,  choice  of,  141 

cleansing  of,  142 


Brandy,  233 
Brea.st,  care  of,  88 

rotation  of,  88 
Breast-fed  infant,   nutritional  dis- 
turbances in,  97 

with  dyspepsia,  102 
Breast-milk,  75 
ash  in,  77 
butyric  acid  in,  77 
calcium  content  in,  77,  78 
carbohydrate  content  of,  77 
casein  of,  76 

chemical  composition  of,  75 
digestibiUty  of,  76 

of  lactalbumin  and  casein  of,  79 
effect  of  menstruation  on,  83 

of  pregnancy  on,  83 
enzjTnes  in,  78 

factors  influencing  the  flow  of,  81 
fat  in,  76,  104 
galactase  in,  78 
human  breasts  and,  72 
in    treatment    of   bronchopneu- 
monia, 292 

of  decomposition,  203 

of  dyspepsia,  188 

of  exudative  diathesis,  258 

of  premature  infants,  248 
intoxication  from,  229 
iron  in,  78 
lactalbumin  of,  76 
lactoglobulin  of,  76 
Upase  in,  78 
milk-sugar  in,  77 
nitrogen  in,  76 
non-protein  nitrogen  of,  76 
olein  in,  77 
palmitin  in,  77 
potassium  of,  76 
protein  content  of,  76 
proteolytic  ferment  in,  78 
reaction  of,  75 
salol-sphtting  ferment  in,  78 
sediment  of,  75 
skimmed,  in  treatment  of  pyloric 

stenosis  and  pylorospasm,  286 


298 


INDEX 


Breast-nursing,  88 

abscess  of  breast  in,  86 

amount  of  food  in,  89 

eczema  in,  276 

tuberculosis  of  breast  in,  86 
Brenneman,  125,  128,  243 
Bromids,  287 
Bronchitis,  291 

acute,    in    exudative    diathesis, 
255 
Bronchopneumonia,   albumin-nulk 
in  treatment  of,  292 

breast-milk     in    treatment     of, 
292 
Budin,  246,  247 

Buttermilk,    Biedert's,    conserve, 
136 

caloric  value  of,  131 

composition  of,  130 

in  intoxication,  229 

preparation  of,  129 
Butyric  acid  in  breast-mUk,  77 

Caffarena,  79 
Caffein  citrate,  207 
Calciiun,  action  of,  on  weight,  47 
chlorid,  233,  287 
content  and  high  casein  in  soap 
stools,  41 
in  blood,  47 
of  breast-milk,  77,  78 
of  cows'  milk,  119 
in  fat  metabolism,  41 
increased  excretion  of,  in  para- 

thyroidectomized  dogs,  271 
lactate,  260,  270 

in  dyspepsia,  189 
metabolism  of,  45,  50 
carbohydrates  in,  46 
in      spasmophilic      diathesis, 

259 
milk  fat  in,  46 

retention  of  nitrogen  in,  46 
retention  of,  45,  46 
in  rickets,  269 
Calomel,  111,  245 


Calomel  in  intoxication,  230 
Caloric  value  as  guide  in  artificial 
feeding,  145 
of  colostrima,  74 
Camphorated  oil  in  decomposition, 

207 
Cane-sugar,  149 
absorption  of,  42 
composition  and  caloric  value  of, 

133 
in  dyspepsia,  179 
in  intoxication,  210 
in  protein  metabohsm,  37 
in  treatment  of  dyspepsia,  188 
of  weight  disturbance,  175 
Cannon,  29 

Carbohydrate   content   of  breast- 
milk,  77 
metabohsm,  42 
Carbohydrates,  132 
in  calcium  metabohsm,  46 
in  treatment  of  weight  disturb- 
ances, 175 
of  cows'  milk,  119 
Carneiro,  43 
Carnick's  food,  136 
Carpopedal  spasm,  262 
Carrot  soup,  135 
Carrots,  155,  258 

Casein,  digestibUity  of,  in  breast- 
milk,  76 
high,    and   calcium   content   in 

soap  stools,  41 
of  breast-mUk,  76 . 
of  colostrum,  73 
Caseinogen  of  cows'  milk,  119 
Castor  oil.  111,  245 

in  constipation,  244 
in  intoxication,  230 
Casts  in  urine  in  intoxication,  218 
Cereal  gruels,  155 
Cereals,  276 

in  intoxication,  229 
Cerebrospinal  meningitis,  239 
Charcoal,  235,  238 
in  intoxication,  232 


INDEX 


299 


Chemical  composition  of  colostrum, 
73 
of  fat  of  body,  40 
Chickou-broth  in  intoxication,  229 
Child,  normal,  60 
Chloral  hydrate,  233,  264 

in  brciwt-milk,  79 
Chlorin    and    nitrogen    in    protein 
metabolism,  37 

mctaboUsm  of,  51 

of  cows'  milk,  119 
Chloroform,  264 

in  breast-milk,  79 
Cholera  infantum,  208 
Chymogen,  127,  130 
Clark,  241 
Cleft-palate,  87,  98 
Clock,  189 

Clothes  in  decomposition,  206 
Codcin,  115 

Cod-hver  oil,  169,  257,  258,  263, 
269,  272,  292 
composition  of,  137 
in  phosphorus  metabolism,  50 
Cold  sponges  in  intoxication,  231 
Cohc,  104,  109 

treatment  of,  113 
Collapse    in    decomposition,    195, 

197,  198 
Colonic  flushings,  243,  244 
in  intoxication,  231 
in  meteorism,  239 
Colostrum,  73,  74 

ash-content  of,  73 

caloric  value,  74 

casein  of,  73 

chemical  composition  of,  73 

corpuscles  of,  74 

fat  of,  73 

globulin  of,  73 

lactalbumin  of,  73 

phosphorus  content  of,  73 

protein  of,  73 

salts  of,  73 

sediment  of,  73 

sugar  of,  73 


Comby,  233 
Condensed  milk,  125 

in  decomposition,  191 
in  dyspepsia,  179 
in  infantile  scurvy,  273 
tubercle  bacillus  in,  127 
Congenital    anomalies    in    pyloric 

stenosis,  281 
Constipation,  243,  266 
atonic,  244 
fat,  168 

in  decomposition,  197 
in  weight  disturbance,  169,  174 
Convulsions,  259,  262 
in  decomposition,  198 
in  intoxication,  217,  219 
in  weight  disturbance,  173 
Cooper,  212 

Copper  in  breast-milk,  80 
Courtney,  192 
Cowie,  287 

Cows'  milk,  bacteria  in,  118 
carbohydrates  in,  119 
chemical  composition  of,  119 
constituents  of,  119 
fat  of,  119 

general  characteristics  of,  119 
lactose  in,  119 
protein  in,  119 
requisites  for  good,  116 
specific  gravity  of,  119 
Crackers,  arrow-root,  155 

graham,  155 
Cradle  cap,  252 
Cream,  128 

caloric  value  of,  133 
Creatin,  39 
Crcatinin,  38,  39 
Cretinism,  201,  293 
Csonka,  ISO 
Culbreth,  133 
Curds,  fatty,  in  stool,  242 
for  food  in  intoxication,  228 
in  stools,  159,  242 
in  dyspepsia,  182 
in  intoxication,  216 


300 


INDEX 


Curds  in  stools  of  breast-fed  infant 
in  undemoiirishment,  99 
protein,  242 
of  millc  in  treatment   of   spas- 
mophilic diathesis,  262 
Cyanosis  in  decomposition,  202 
Cyanotic  attacks  in  premature  in- 
fants, 249 
Czerny,  69,  74,  100,  125,  145,  157, 

190,  211,  251,  254,  255 
Czemy-KeUer,  24,  132 

Davidsohn,  31,  75,  78 
Decomposition,  109,  162,  174,  186, 

190,  219,  220 
absorption  by  intestinal  mucosa 

in,  193 
albumin-milk  in   treatment   of, 

206 
bathing  in,  207 
breast-milk  in,  203 
clothes  in,  206 
collapse  in,  197,  198 

weight  in,  196 
condensed  milk  in,  191 
constipation  in,  197 
convulsions  in,  198 
cyanosis  in,  202 
diarrhea  in,  198 
drooling  in,  197 
duodenal  ulcers  in,  191 
eczema  in,  194 
emaciation  in,  193 
eructation  of  gas  in,  197 
himger  in,  197 
in  breast-fed  infant,  97,  115 
in  winter  months,  191 
malt   extract   in   treatment   of, 
205,  206 

food  in,  205,  206 
medicinal  treatment  in,  207 
of  food  in  meteorism,  239 

in  stomach  in  eructation   of 
gas,  234 
paradoxic  food  reaction  in,  196, 

199 


Decomposition,  prolapse  of  rectum 
in,  198 

pulse  in,  198 

skimmed  milk  in  treatment  of, 
204 

skin  in,  194 

sleep  in,  198 

soap  in  stool  in,  192 

stomach  washing  in,  207 

subnormal  temperature  in,  194 

suppositories  in,  207 

terminal  pneumonia  in,  198 

tissue  turgor  in,  194 

urine  in,  198 

vomiting  in,  207 
Denney,  211 
Dent,  279 

Deodorized  tincture  of  opium,  115 
Dextrimaltose,  133 
Dextrin  in  infant  foods,  44 
Diarrhea,  bUe  in,  241 

bihverdin  in,  242 

bismuth  in,  241 

color  of  stools  in,  241 

consistency  of  stools  in,  241 

gases  formed  in  stools  in,  241 

hydrobiUrubin  in  stools  in,  241 

in  acute  iofectious  diseases,  288 

in  congenital  syphUis,  289 

in  decomposition,  198 

in  dyspepsia  of  breast-fed  infant, 
106 

in  intoxication,  213,  216,  231 

mucus  in  stools  in,  242 

odor  of  stools  in,  241 

putrefaction  in,  241 

reaction  of  putrefaction  in,  241 

stools  in,  240 
in  congenital  sypbiHs,  240 
in  intoxication,  240 
in  miliary  tubercidosis,  240 
in  pyelocystitis,  292 

urobilinogen  in,  241 
Diathesis,  exudative,  108,  168,  251 

spasmophilic,  108,  259 
Digestion  of  fat,  34 


INDEX 


301 


Digestive  activity  of  stomach,  30 
Distention  in  dyspepsia  of  breast- 
fed infant,  107 
of  abdomen  in  dyspepsia,  182 
of  intestine  in  weight  disturb- 
ance, 171 
Dover's  powder,  115 
Drooling,  29 

in  decomposition,  197 
Drugs  in  breast-milk,  79 
DuBois,  46 
Duodenal  ulcers  in  decomposition, 

191,  198 
Duodenum  in  pyloric  stenosis  and 

pylorospasm,  281 
Dysentery,  208 

Dyspepsia,  162,  171,  174,  178,  190, 
220 
albumin-milk   in   treatment   of, 

187 
ammoniacal  urine  of  breast-fed 

infant  in,  108 
barley-water  in  treatment  of,  187 
bath  in,  188 
bismuth  in,  189 
breast-milk  in,  188 
cane-sugar  in,  179,  188 
condensed  milk  in,  179 
curds  in,  182 
diarrhea  in  breast-fed  infant  in, 

106 
distention  of  abdomen  in,  182 

of  breast-fed  infant  in,  107 
eructation  of  gas  in,  181 
etiologj'  of,  178 
fat  in,  179 

flatus  in  breast-fed  infant  in,  106 
fresh  air  in,  188 
in  breast-fed  infant,  97,  102 
malt  extract  in  treatment  of,  187 

food  in  treatment  of,  187 
milk-sugar  in,  179 

in  treatment  of,  188 
pulse  of  breast-fed  infant  in,  107 
respiration  of  breast-fed  infant 
in,  107 


Dyspepsia,  saccharin  in  treatment 

of,  187 
skimmed  milk  in  treatment  of, 

187 
stomach  washing  in,  189 
stools  in,  181 
sugar  in,  181 
temperature  in,  182 

of  breast-fed  infant  in,  107 
tissue-turgor  of  breast-fed  infant 

in,  107 
urine  in,  182 
vomiting  in,  181,  188 

in  breast-fed  infant  in,  106 
weight  in,  183 

curve  in,  in  breast-fed  infant, 
109 

Eczema,  108,  172,  174,  201,  256 
in  decomposition,  194 
infant-feeding  in,  275 
milk,  253 

Edelstein,  73,  78,  180 

Edema,    generalized,    in   intoxica- 
tion, 219 

Eggs,  137,  155,  258,  267 
in  intoxication,  229 

Elastic  tissue  of  intestines,  25 

Electric    irritabihty    in    spasmo- 
philic diathesis,  259,  261 

Emaciation  in  decomposition,  193 

Emotions  in  breast-nursing,  86 

Endocarditis,  225 

Enema,   continuous  sahne,   in  in- 
toxication, 233 

Enemas  in  meteorism,  239 

Engel,  77,  145 

Enterococcus,  56,  58 
in  mouth,  53 
in  small  intestine,  54 

Enterokinase,  33 

EnzjTnes  in  breast-milk,  78 

Eosinophiha  in  exudative  diathesis, 
256 

Erdheim,  270 

Erepsin,  33 


302 


INDEX 


Eructation  of  gas,  234 

acacia  in,  235 

bismuth  ia,  235 

charcoal  in,  235 

in  decomposition,  197 

in  dyspepsia,  181 

in  intoxication,  216 

regurgitation   from   the   duo- 
denum in,  234 

stomach  washing  in,  235 

swallowing  of  air  in,  234 

vomiting  with,  235 
Escherich,  57,  211,  260 
Eskay's  food,  136 
Esophagus  and  stomach,  23 
Ether,  286 

in  breast-milk,  79 
Etiologic    classification    of    nutri- 
tional disturbances  of  artificially 
fed  infant,  157 
Exudative  diathesis,  168,  251 

acute  bronshitis  in,  255 

body  weight  in,  252 

immunity  in,  256 

in  weight  disturbance,  174 

Facies  in  intoxication,  214 
Fat,  absorption  of,  41 

and  digestion  of,  34 
amount  of,  in  artificial  food  for 

infant,  148 
and  nitrogen  retention,  41 
as  cause  of  weight  disturbance, 

169 
constipation,  168 
content,  change  of,  in  milk,  128 

high  in  milk  in  vomiting  of 
breast-fed  infant,  237 

in  breast-milk,  76 
curds  in  stool,  242 
etiology  of,  in  furunculosis,  293 
food  rich  in,  in  rickets,  269 

in  treatment  of  rickets,  271 
globules  in  colostrum,  74 
in  breast-milk,  76,  104 
in  cheeks,  27 


Fat  in  dyspepsia,  179 

metabohsm,  40,  41 
calcium  in,  341 
phosphorus  in,  41 

milk-,  in  treatment  of  exudative 
diathesis,  257 

of  body,  chemical    composition 
of,  40 

of  colostrum,  73 

of  cows'  milk,  119 
Feces,   injection  of  alcoholic  and 

aqueous   solutions   of,   in   dogs, 

269 
Feeding,  amount  to  be  given  each, 

147 
Feedings,  mixed,  96,  103 
Feer,  von,  287 
Fermentation,  58 

Fetor  ex  ore  in  exudative  diath- 
esis, 255 
Fever  due  to  sugar,  44 

in  intoxication,  231 

inanition,  101 
Figs,  258 

syrup  from,  245 
Finizio,  76 
Finkelstein,  42,  97,  130,  162,  206, 

210,  212,  263,  277 
Finkelstein's  diet  in  eczema,  277 
Fischer,  233 

Flatus  in  dyspepsia  of  breast-fed 
infant,  106 

in  intoxication,  217 
Flesch,  198,  242 

Flour-ball  in  artificial  feeding,  149 
Fontanel,  anterior,  66 
Food,  amount  of,  in  breast-nursing, 
89 

length  of  time  in  stomach,  30 

tolerance  for,  in  normal  infant, 
70 
Foods,  fat,  phosphorus  metabolism 
in,  50 

used  in  artificial  feeding,  116 
Forte,  269 
Frank,  192 


INDEX 


303 


Fresh  air,  112 

in  decomposition,  206 
in  dyppopsiii,  188 
in  intoxication,  230 
in   treatment   of   nervous   in- 
fant, 2G7 
of    spasmophilic    diathesis, 
262 
in  weight  disturbance,  177 
Fretfulness  in  weight  disturbance, 

169 
Freund,  51,  275 
Fruit  juices,  155 
Furunculosis,  219,  293 
fat  in  etiology  of,  293 
sugar  in  etiology  of,  293 

Galactase  in  breast-milk,  78 
Galactorrhea,  98 
Galactose  in  urine,  42 

in  intoxication,  218 
Gastric  contents  in  pyloric  stenosis 
and  pylorospasm,  283 
lavage,  287 

in  whooping-cough,  288 
peristalsis  in  pyloric  stenosis  and 
pylorospasm,  282 
Gastro-enterostomy,  posterior,  286 
Gastro-intestinal    disturbances    in 
rickets,  269 
symptoms    in    weight    disturb- 
ance, 170 
tract,  anatomy  of,  21 
bacteriology  of,  53 
physiology  of,  27 
wall,  permeabiUty  of,  33 
Gavage,  248 
Gelatin,  157 
Gerstenberger,  260 
Glands,  lymphatic,  in  normal  in- 
fant, 66 
of  intestines,  24 
GlobuUn  of  colostrum,  73 
Gluten  suppositories,  244 
Glycerin  suppositories,  244 
GlycocoU,  40 


Glycogen  in  liver,  33 
Glycosuria  in  premature  infants,  43 
Graham  crackers,  155 
Grape-sugar  in  intoxication,  210 
Gruels,  cereal,  155 

Hahn,  33,  34 

Harelip,  87,  98 
Harley,  25 
Hart,  273 
Haskins,  260 
Hayashi,  193 

Heart  disease,  congenital,  201,  291 
malnutrition  in,  291 

valvular  or  muscular  diseases  of, 
as  an  indication  for  removal 
of  child  from  breast,  85 
Heat  in  intoxication,  209 
Heim,  45,  131 
Heineman,  129 
HeUer,  100 

Helmholz,  40,  192,  198,  227 
Hemorrhage  into  gums  in  infantile 
scurvy,  273 

subperiosteal,  in  infantile  scurvy, 
273 
Hess,  31,  33, 198,  213,  243,  283,  284 
Heubner,  145,  286 
HiU,  131 

Hippuric  acid  in  urine,  40 
Hirschfeld,  218 
HofTa,  284 

Holt,  24,  115,  127,  139,  198,  213 
Homogenization  of  milk,  129 
Hoobler,  131 
Horlick's  food,  136 

malted  mUk,  136 
Huldschinsky,  ISO,  181 
Human  breast  and  breast-milk,  72 
Hume,  233 
Hunger,  51 

in  decomposition,  197 
Hydrobilirubin  in  stool  in  diarrhea, 

241 
Hydrochloric  acid,  free,  in  stomach, 

30,  31 


304 


INDEX 


Hygienic    measurea   in   exudative 

diathesis,  257 
Hyperacidity  of  stomach  in  pyloro- 

spasm,  283 
Hypo-acidity  of  stomach  in  pyloro- 

spasm,  283 

Ibrahim,  243,  279,  285 
Ice-cap  to  head  ia  intoxication,  231 
Icterus  neonatoriun,  26 
Idiocy,  293 
Ileocolitis,  208 

Immunity  in  exudative  diathesis, 
256 
in  normal  infant,  70 
Imperial  granum,  136 
Inanition  fever,  99 
Incubators,  247 
Indican  in  urine,  40 
Infants,  marantic,  with  dyspepsia, 
178 
premature,  glycosuria  in,  43 
lactose  in  stools  of,  42 
Infectious  diarrhea,  208 

diseases,  acute,  as  indication  for 
removal    of    chUd    from 
breast,  84 
vomiting  in,  288 
Insanity  as  an  indication  for  re- 
moval of  child  from  breast,  85 
Intertrigo,  253 

from  ammoniacal  virine,  172 
Interval,  four-hour,  111 

of  breast-fed  infant,  103 
length  of,  between  nursings,  146 
lengthening  of,  between  feedings, 

238 
regular,  in  breast-feeding,  103 
Intestinal   mucosa   in   decomposi- 
tion, absorption  by,  193 
wall,  paresis  of,  in  meteorism, 
239 
spasm  of,  114 
Intestine,  24 

small,  bacteria  in,  54 
enterococcus  of,  54 


Intoxication,   109,   162,   171,   174, 

185 
acacia  in,  231 
acetozone  in,  231 
acidosis  in  uriue  in,  213 
albumin  in  urine  in,  218 
albumin-water  in,  229 
alcohol,  233 

ammonia-content  of  urine  in,  213 
bacillus  acidophilus  in,  212 

coU  communis  in,  211 

dysenteriae  in,  211 

pyocyaneus  in,  212 
barley-water  in,  227 
bathing  in,  226,  230 
baths,  cold,  in,  231 
bismuth  in,  232 
brandy  in,  233 
breast-milk  in,  229 
buttermilk  in,  229 
calomel  in,  230 
castor  oil  in,  230 
casts  ia  vtrine  in,  218 
cereals  in,  229 
charcoal  in,  232 
chicken-broth  in,  229 
chloral  hydrate  in,  233 
cold  bath  in,  231 

sponges  in,  231 
collapse  ia,  232 
colonic  flushings  in,  231 
comatose  state  in,  233 
continuous  sahne  enema  in,  233 
convulsions  in,  217,  219,  233 
curds  for  food,  228 

in  stool  in,  216 
dehrium  in,  233 
diarrhea  in,  233,  216,  231 
edema,  generaUzed,  in,  219,  233 
eggs  in,  229 

eructation  of  gas  in,  216,  232 
facies  in,  214 
fever  in,  231 
flatus  in,  217 
fresh  air  in,  230 
galactose  in  urine  in,  218 


INDEX 


305 


Intoxication,  grape-sugar  in,  210 

heat  in,  209 

hydrotherapcutic    measures    in, 
233 

ice-cap  to  head  in,  231 

in  breast-fed  infant,  97,  115 

lactose  in  urine  in,  213,  218 

leukocytes  in  blood  in,  218 

loss  of  weight  in,  214 

malt-sugar  in,  210 

meat-broth  in,  229 

mctcorism  in,  217,  218,  232 

milk-sugar  in,  210 

mucus  in  stool  in,  216 

opium  in,  231 

paregoric  in,  231 

potassium  chlorid  in,  233 

prolapse  of  rectum  in,  217,  232 

pulse  in,  216 

respiration  in,  216 

saccharin  in,  227 

saccharose  in  urine  in,  219 

silver  nitrate  in,  231 

skimmed  milk  in,  229 

skin  in,  217 

sodium  chlorid  in,  233 

specific  action  of  pathogenic  bac- 
teria in,  213 

stomach  washing  in,  232 

streptococcus  in,  211 

strychnin  sulphate  in,  233 

subcutaneous  salines  in,  233 

sugar  in  food  in,  227 

sugar-cane  in,  210 

tannic  acid  in,  232 

temperature  in,  215 

tissue-turgor  in,  218 

Tokay  wine  in,  233 

urine  in,  218 

vegetable  soup  in,  229 

vomiting  in,  216,  232 
Intussusception,  238 
Invertin   in   pancreatic    secretion, 
33 

in  succus  entericus,  33 
lovane,  269 
20 


Iron  in  breast-milk,  78,  79 
of  cows'  milk,  119 

Jehle,  211,  243 
John,  131 
Jorgensen,  45 
Jundell,  80,  180,  181,  183 

Kabsowitz,  67,  271 

Katzenellenbogen,  49 

Kehrer,  259 

Keller,  17,  69,  100.  125,  133,  157, 

211 
KeUer-Czerny,  24,  132 
Kelly,  284 

Kephir,  composition  of,  140 
Klduffe,  211 
Kleinschmidt,  25,  70,  80 
Klochmann,  274 
Klotz,  44 
Koumiss,  composition  of,  139 

Lactalbumin,  digestibihty  of,  in 
breast-milk,  76 

of  breast-milk,  76 

of  colostrum,  73 

of  cows'  mUk,  119 
Lactase  in  pancreatic  secretion,  33 

in  stools  of  premature  infants,  43 

in  succus  entericus,  33 
Lactic  acid  bacillus.     See  Bacillus 

ladis  ai'rogcnes. 
Lactoglobulin  of  breast-milk,  76 

of  cows'  milk,  119 
Lactopreparata,  136 
Lactose,  103.     See  Milk-sugar. 

in  urine,  42 

in  intoxication,  213 

of  cows'  milk,  119 
Ladd,  30 

Lane-Claypon,  125 
Lange,  de,  Cornelia,  77 
Langstein,  38,  50,  73,  76,  288 
Laryngospasm,  262 
Lecithin  in  protein  metabohsm,  37 
Leimnahrschaden,  157 


306 


INDEX 


Lempp,  76 

Length  of  interval  in  premature  in- 
fants, 248 
of  normal  infant,  64 

Leopold,  43 

Lessing,  273 

Leukocytosis,  polynuclear,  from  in- 
jection of  sodium  chlorid,  49 
in  blood  in  intoxication,  218 

Lewald,  30 

Lewis,  123 

Liefmann,  40,  260 

Lime-water,  138 

Lipase  in  breast-milk,  78 
in  stomach,  32 

Litzenberg,  249 

Liver,  25 

glycogen  in,  33 

physiology  of,  33 

protection   against   poisons   by, 

33 
urea  in,  33 
weight  of,  25 

Long  intervals  in  treatment  of  py- 
loric stenosis  and  pylorospasm, 
286 

Lung  affections,  chronic,  201 

Lust,  33,  34,  256,  274 

Lymph-glands  in  weight  disturb- 
ance, 172 

MacCallum,  271 
Magnesia,  milk  of,  245 
Magnesium,  metabolism  of,  50 
of  cows'  milk,  119 
sulphate  in  spasmophilia,  263 
Major,  23,  30 
Malaria,  225 
Mahiutrition,  190 

in  congenital  heart  disease,  291 
Malt  extract,  134 

causing  vomiting,  237 
composition  of,  133 
in  treatment  of  decomposition, 
205,  206 
of  dyspepsia,  187 


Malt    extract    in    treatment     of 
weight  disturbance,  176 

food  in  treatment  of  decomposi- 
tion, 205,  206 
of  dyspepsia,  187 
Maltase  in  succus  entericus,  33 
Malted  milk,  HorUck's,  136 
in  infantUe  scurvy,  273 
Maltose.     See  Malt-sugar. 
Malt-sugar,  133,  275 

absorption  of,  42 

in  artificial  feedings,  149 

in  intoxication,  210 

in  protein  metabolism,  37 

in  treatment  of  weight  disturb- 
ance, 175,  176 
Mammary  gland,  human,  72 
Marasmus,  190 

in  breast-fed  infant,  115 
Marfan,  269 

Matzoon,  composition  of,  139 
Mayerhofer,  136,  193 
McCampeU,  127 
Meat,  267 

broth  in  intoxication,  229 
Mehhiahrschaden,  157,  190,  194 
Meigs,  43 
MeUen's  food,  136 
Meningitis,  cerebrospinal,  239 
Mensi,  62 

Menstruation,  effect  of,  on  breast- 
milk,  83 
Mercury  in  breast-milk",  79 
MetaboHsm  and  absorption,  36 

calcium,  45,  50 
in  spasmophihc  diathesis,  259 

carbohydrate,  42 

chlorin,  51 

fat,  40,  41 

in  eczema,  275 

in  scurvy,  273,  274 

magnesiima,  50 

of  inorganic  salts,  44 

of  phosphorus,  50 

of  potassium,  49,  50 

of  protein,  36 


INDEX 


307 


Metabolism  of  sodium  salts,  48 
of  Mugiir,  43 

in  eczema,  275 
sulphur  in,  51 
Mctcorism,  239 
colonic  flushings  in,  239 
decomposition  of  food  in,  239 
enoina;^  in,  239 
in  intoxication,  217,  218 
intestinal  antiseptics  in,  239 
paresis  of  the  intestinal  wall  in, 

239 
tiu-pentinc  stupes  in,  239 
Meyer,  50,  51,  130,  206,  210,  269 
Micrococcus  ovalis,  56 
Milchniihrschaden,  157,  168,  169 
Milk,  adulteration  of,  122 
bacterial  content,  120 
boUed,  in  infantile  scurvy,  273 
caloric    values    of,    and    of    its 

derivatives,  131 
change  of  fat-content  in,  128 
condensed,  43,  125 
cows',  116 
fat-free,  129 

caloric  value  of,  131 
germicidal  action  of,  123 
homogenization  of,  129 
pasteurization   and  sterihzation 

of,  124 
peptonization  of,  128 
sediment  of,  123 
skimmed,  129 

in  intoxication,  229 
in    treatment    of    decomposi- 
tion, 204 
of  dyspepsia,  187 
of  pylorospasm,  287 
to  determine  amount  of,  which 
is  obtained  from  the  breast,  92 
whole,  caloric  value  of,  131 
Milk-fat  in  calcium  metabolism,  46 
Milk-sugar,  276 
amount  of,  in  artificial  food  for 

infant,  149 
causing  vomiting,  237 


Milk-sugar,  composition  and  calo- 
ric value  of,  133 

in  brea.st-milk,  77 

in  dyspepsia,  179 

in  intoxication,  210 

in  protein  metabolism,  37 

in  stool,  42 

in  treatment  of  dyspepsia,  188 

injection  of  solution  of  43 
Miller,  280,  283 
Mixed  feeding,  96 
Moll,  50,  68 
Moro,  55,  135,  211 
Morphin,  115,  264 
Motor  activity  of  stomach,  29 
Mouth,  bacillus  coli  commimis  in, 
53 
perfringens  in,  53 

bacteria  in,  53 

enterococcus  in,  53 

pneumococcus  in,  53 

streptococcus  in,  53 
Mucus  in  stool  in  diarrhea,  242 

in  intoxication,  216 
Muscular  action  in  normal  infant, 

69 

NASOPHARYNGE.iL  infections,  186 
Nasopharyngitis,  108,  110, 184,  291 
disturbance  from  swallowing  of 
mucus  in   otitis  media  from, 
293 
in  weight  disturbance,  173 
Nasophar\Tix,  mucus  formation  in, 

234 
Negro  babies,  270 
Nephritis  as  indication  for  removal 

of  child  from  breast,  85 
Nervous  infant,  265 

symptoms  in  weight  disturbance, 
173 
of  pyloric  stenosis  and  pyloro- 
spasm, 282 
system  in  normal  infant,  69 
Nestle's  food,  136 
Neurath,  47 


308 


IXDEX 


Niemann,  38,  39,  50,  169 
Nipples,  72 

care  of,  88 

choice  of,  141 

inverted,  86,  98 

painful,  in  nursing,  86 
Nitrogen  and  chlorin,  37 

balance,  38 

division  of,  in  food,  38 

in  urine,  39 

non-protein,  of  breast-milk,  76 

of  breast-milk,  76 

retention  of,  and  fat.  41 
in  calcium  metabolism,  45 

sources  of,  in  stool,  37 
Normal  infant,  artificial  feeding  of, 

141,  146 
Nothmann,  42 
Nourishment  during  second  j'ear, 

154 
Nursing,  intervals  between,  90 

position  of  child  vrhile,  88 

regularity  in,  91 
Nutritional  disturbances  of  artifi- 
cially fed  infant,  156 
etiologic    classification, 
157^^ 
of  breast-fed  infant,  97 
Nutrose,  138' 

Oat  flour,  134 

Oatmeal,  276 

composition  and  caloric  value  of, 

133 
in  artificial  feeding,  149 

Oiled  paper  cone,  245 

Olein  in  breast-milk,  77 
of  cows'  milk,  119 

OHve  oil,  137,  169,  245 

Opiate,  287 

Opium,  115,  231 

Opsonic  index  in  exudative  diath- 
esis, 256 

Oral  cavity,  21 

Orange-juice,  155,  245,  274 
in  weight  disturbance,  177 


Oranges,  258 

Orgler,  46,  78,  269 

Osmosis,  193 

Otitis  media,  108, 110, 184,  221,  293 

disturbance   from   swallowing 

mucus,  293 
from  nasopharjmgitis,  293 
in  weight  disturbance,  173 
Overfeeding  in  premature  infanta, 
249 
of  breast-fed  infant,  102 

Pacchioxi,  194 

Pain  in  cutting  teeth,  28 

Pallor  in  breast-fed  infant  in  under- 
nourishment, 100 

Palmitin  in  breast^milk,  77 
of  cows'  milk,  119 

Pancreas,  25,  32 

Paper  cone,  oiled,  245 

Paradoxic  food  reaction  in  decom- 
position, 196,  199 

ParathjToid  glands,  268,  270 

in  spasmophilic  diathesis,  266 

Paregoric,  115,  231 

Paresis  of  intestinal  wall  in  meteor- 
ism,  239 

Pasteiuization  of  milk,  124 

Pehu,  135 

Peiser,  140 

Peppermint-water,  115 

Pepsin  in  stomach,  30,  32 

Peptonization  of  milk,  128 

Perigastric  adhesions,  284 

Peristalsis,  gastric,  in  pyloric  sten- 
osis and  pylorospasm,  282 

Pfaundler,  24,  280 

Phar^mgitis,  repeated  attacks  of,  in 
exudative  diathesis,  254 

Phenacetin  in  breast-milk,  79 

Phosphates  of  cows'  milk,  119 

Phosphorus,  263,  270,  272 
absorption  of,  50 
in  colostrum,  73 
in  fat  metabolism,  41 
in  urine,  50 


INDEX 


309 


Phosphorus  metabolism,  50 
in  cod-liver  oil,  50 
with  fat  foods,  50 
Pirquet,  von,  167 
PLsek,  30 

Placental  extract,  injections  of,  to 
produce     secretion     of     breast- 
milk,  81 
Pneumococcus  in  mouth,  53 
Pneumonia,  108,  110, 18G,  218,  224, 
239 
broncho-,  292 
hjTJOstatic,  218 

terminal,  in  decomposition,  198 
Poisons,    protection    against,    by 

Uver,  33 
Potassium  chlorid,  233,  287 
in  breast-milk,  76 
metabolism  of,  49,  50 
of  cows'  milk,  119 
Potato,  baked,  274 
Predisposition,  congenital,  268,  271 
Pregnancy,   effect    of,    on   breast- 
milk,  S3 
Premature  infant,  246 
breast-milk  for,  248 
cyanotic  attacks  in,  249 
length    of    interval    between 

feedings,  249 
overfeeding  in,  249 
undernourishment  in,  249 
vomiting  in,  248 
Pribram,  136,  193 
Proprietary  foods,  135 
Protective    application    in    treat- 
ment of  eczema,  276 
Protein,  157 

amount  of,  in  artificial  food  for 

infant,  148 
content  of  breast-milk,  76 
curds  in  stools,  242 
metaboUsm,  92 

ammonia  coefficient  in,  37,  39 
cane-sugar  in,  37 
in  first  five  to  eight  days,  38 
lecithin  in,  37 


Protein  metabolism,  milk-sugar  in, 
37 
of  colostrum,  73 
of  cows'  milk,  119 
Proteolytic  ferment  in  breast-milk, 

78 
Prune-juice,  155,  245 
Primes,  258 
stewed,   in  weight  disturbance, 
177 
Prurigo,  254 

Pulse  in  decomposition,  198 
in  dyspepsia  of  breast-fed  infant, 

107 
in  intoxication,  216 
in  normal  infant,  65 
Putrefaction,  58 
in  diarrhea,  241 
source  of,  59 
Pyelocystitis,   108,   110,  201,  219, 
220,  292 
diarrhea  in,  292 
Pyloric   stenosis,   congenital,   201, 
239,  279 
tumor  in  fetus,  279 
in  pyloric  stenosis,  283 
Pylorospasm,  201,  279 
Pylorus,  24 

hx^pertrophy  of  circular  muscular 
coat    of,  in    pyloric   stenosis, 
281 
in  pyloric  stenosis,  280 

QuiNiN  in  breast-milk,  79 

Rachmilewitsch,  254 
Ramogen,  Biedert's,  136 
Reaction  of  breast-milk,  75 
Rectum,  prolapse  of,  in  decompo- 
sition, 198 
in  intoxication,  217 
Reed,  79 
Regularity  in  treatment  of  nervous 

infant,  266 
Regurgitation  from  duodenum,  234 

of  food,  235,  236 


310 


INDEX 


Removal  of  child  from  breast,  in- 
dications for,  84 

Rennet,  30 

Respiration  in  dyspepsia  of  breast- 
fed infant,  107 
in  intoxication,  216 
in  normal  infant,  65 

Reuss,  von,  42,  43,  98,  100,  260 

Rice-flour,  composition  and  caloric 
value  of,  133 

Rickets,  175,  191 
infant  feeding  in,  268 

Ridge's  food,  136 

Rietschel,  42,  210 

Rockefeller  Institute,  211 

Rosenau,  121 

Rosenstern,  49,  98,  259,  287 

Rothberg,  45 

Rott,  62,  73 

Rubner,  145 

Rubrah,  134 

Rumination  in  pylorospasm,  281 

Rupp,  124 

Sacchaein,  111,  187,  237 

Saccharose  in  urine,  29,  218 

Sainmont,  44 

Salge,  218 

Salicylic  acid  in  breast-milk,  79 

SaMne  enema,  continuous,  286 

Salines,  subcutaneous,  in  intoxica- 
tion, 233 

SaUvary  glands,  21 
secretion,  27 

Salol-splitting  ferment  in  breast- 
milk,  78 

Salt  solution,  introduction  of,  by 
mouth,  48 

Salts,  inorganic,  metaboUsm  of,  44 
physiologic  effects  on  body,  47 
of  colostrum,  73 

Salvarsan  in  breast-milk,  79 

Samelson,  49,  145,  249 

Schabad,  269 

Schelble,  191,  192 

Schloss,  45,  49,  77 


Schlossman,  192 
Scrofulosis,  289 

carbohydrate-rich  diet  in,  289 
cereals  in,  289 
vegetables  in,  289 
Scurvy,  infantile,  273 

metaboHsm  in,  273,  274 
Seborrhea,  108,  172,  174 
Second  year,  nourishment  during, 

154 
Secretion,  amoimt  of,  in  stomach, 

32 
Seel,  134 
Senna,  245 
Sigmoid,  25 
Silver  nitrate,  231 
Sinclair,  189,  231 
Sisto,  114 
Sittler,  54,  55 
Skin  at  birth,  65 

in  decomposition,  194 
in  intoxication,  217 
in  weight  disturbance,  172 
reaction  in  exudative  diathesis, 
254 
Skull,  soft  spots  in,  67 
Sleep  in  decomposition,  198 
Small    intestine,     bacillus    acido- 
philus in,  55 
mesentericus  in,  55 
putrificus  in,  55 
butyric  acid  bacillus  in,  55 
staphylococci  in,  55 
streptococcus  acidi  lactici  in, 
54 
Soap  in  stool  in  decomposition,  192 
stools  in  weight  disturbance,  170 
suppositories,  245 
Sodium  bicarbonate,  138 
chlorid,  48,  138,  233,  287 
leukocytosis  from  injections  of, 

49 
solution,  rise  of  temperature 
from  injection  of,  48 
citrate,  138,  287 
in  breast-milk,  79 


INDEX 


311 


Sodium   metabolism,  retention  of 
water  in,  48 

of  cows'  milk,  119 

salts,  metabolism  of,  48 
Soja  bean,  134 
Somatose,  138 

Biedert's,  136 
Southworth,  44 
Spasm  of  intestinal  wall,  114 

rotary  head,  2G2 
Spasmophilic  diathesis,  259,  285 
Spinach,  155,  258 
Staphylococci  in  breast-milk,  80 

in  cows'  milk,  121 

in  small  intestine,  55 
Staphylococcus    albus    in    breast- 
milk,  80 
Starch  in  stool,  42 

in  treatment  of  exudative  diath- 
esis, 257 
Starches,  267 

in  artificial  feeding,  149 

in  treatment  of  weight  disturb- 
ance, 175 
Steapsin,  33 
Stearin  in  breast-milk,  77 

of  cows'  mill<,  119 
Sterilization  of  milk,  124 
Stolte,  46,  193,  229 
Stolzner,  270 
Stomach,  23,  29 

acidity  of,  30 

amount  of  secretion  of,  32 

bacteria  in,  54 

capacity  of,  24 

digestive  activity  of,  30 

free  HCI  in,  30 

in  pyloric  stenosis,  280 

lipase  in,  32 

motor  activity  of,  29 

overfilling  of,  236 

pepsin  in,  30,  32 

rennet  in,  30 

systolic  contracture  of,  24 

washing,  112,  238 
in  decomposition,  207 


Stomach   washing    in     eructation 
of  gas,  235 

in  intoxication,  232 

in  vomiting  in  dyspepsia,  189 
Stool,  albumin  in,  36 

bacillus  bifidus  communis  in,  57, 
58 

lactis  aerogenes  in,  57,  58 
bacteria  in,  57 
biliverdin  in,  242 
calcium  content  and  high  casein 

in,  41 
color  of,  241 

in  diarrhea,  241 
consistency  of,  241 
curds  in,  159 
fatty  acids  in,  241 
gases  formed  in,  241 
hydrobilirubin  in,  241 
in  diarrhea,  240 
in  dyspepsia,  181 
in  intoxication,  curds  in,  216 

mucus  in,  216 
in  normal  infant,  68 
in  pyloric  stenosis  and  pyloro- 

spasm,  282 
in  undernourishment  of  breast- 
fed infant,  98 
in  weight  disturbance,  170 
milk-sugar  in,  42 
mucus  in,  242 

numbers  of,  in  diarrhea,  240 
odor  of,  241 
reaction  of,  241 
soap,  in  weight  disturbance  in, 

170 
soiu-ces  of  nitrogen  in,  37 
starch  in,  42 
sugar  in,  42 
urobihnogen  in,  241,  242 

in  weight  disturbance  in,  170, 
171 
Streptococci  in  cows'  milk,  121 

in  stool,  243 
Streptococcus    acidi    lactici,    bio- 
logic characteristics  of,  56 


312 


INDEX 


Streptococcus  in  small  intestine,  54 

in  intoxication,  211 

in  mouth,  53 
Strophulus,  254 
Strychnin,  207,  233,  286 
Subcutaneous  tissue,  66 
Succus  entericus,  33 
invertin  in,  33 
lactase  in,  33 
maltase  in,  33 
Sucking,  27 

Sugar.  See  Cane-sugar,  Malt-sugar, 
and  Milk-sugar. 

content,  high,  causing  vomiting, 
237 

dyspepsia  in  nervous  infant,  266 

fever,  44 

in  dyspepsia,  179 

in  etiology  of  furimcvilosis,  293 

in  food  in  intoxication,  227 

in  stool,  42 

metaboHsm,  43 
in  eczema,  275 

of  colostrum,  73 
Sulphur,  acid,  in  urine,  51 

metabolism  of,  51 

neutral,  in  urine,  51 
Summer  diarrhea,  208 
Suppositories,  gluten,  244 

glycerin,  244 

in  decomposition,  207 

in  weight  disturbance,  177 

soap,  245 
Suprarenal  gland,  268 

secretion,  270 
Syphilis  as  an  indication  for  re- 
moval of  child  from  breast,  85 

congenital,  184,  200,  269,  289 
diarrhea  in,  240,  289 
Syphilitic  hydrocephalus,  200,  290 
Systolic  contraction  of  stomach,  24, 

280 

Talbot,  242 
Tannic  acid,  232 
Teeth,  21 


Teeth  begin  to  appear,  67 
cutting,  28,  67 
pain  in,  28 
Teething,  21 

Temperature,  body,  in  premature 
infants,  247 
ciu:ve  in  intoxication,  215 
in   breast-fed   infant   in   imder- 

novuishment,  99 
in  dyspepsia,  182 

of  breast-fed  infant,  107 
in  intoxication,  215 
in  weight  disturbance,  173 
rise  of,  from  injection  of  sodium 

chlorid  solution,  48 
subnormal,  in  decomposition,  194 
variation  of,  in  normal  infant,  64 
Tetany,  259 
Tezner,  48 
Thomas,  74 

Thyroid  extract  in  breast-milk,  80 
Tissier,  55 
Tobler,  51 
Tokay  wine,  233 
Tongue,  geographic,  255 
Tonsillitis,  follicular,  255 
Toxicosis,  208 
Trypsin,  33 
Tubercular  intoxication,  200 

meningitis,  224,  288 
Tuberculosis,  199,  269 

as  an  indication  for  removal  of 

child  from  breast,  84 
miUary,  184,  200,  224,  288 

with  diarrhea,  240 
of  breast  in  breast-nursing,  86 
Turgor,  66 
in   breast-fed   infant   in   under- 
nourishment, 100 
in  decomposition,  194 
in  dyspepsia  of  breast-fed  infant, 

107 
in  intoxication,  218 
in  weight  disturbance,  172 
Tiu-pentine  stupes,  114,  239 
in  intoxication,  232 


INDEX 


313 


Turpentine  stupes  in   meteorism, 

239 
Typhoid  fever,  225,  288 

Ulceration  of  intestine  in  diar- 
rhea, 242 
Undernourishment,  curds  in  stool 
of  breast-fed  infant  in,  99 
in  breast-fed  infant,  98 
in  premature  infants,  249 
pallor  of  breast-fed  infant  in,  100 
stools  of  breast-fed  infant  in,  99 
temperature    in,    of    breast-fed 

infant,  99 
turgor  of  breast-fed  infant  in,  100 
weight  of  breast-fed  infant  in,  99 
Urea  in  Uver,  33 
Uric  acid,  38,  39 
Urine,  acetone  in,  40 
in  spasmophiha,  260 
acid  sulphur  in,  51 
albumin  in,  218 
ammonia  content,  39 
in  intoxication,  213 
in  weight  disturbances,  172 
ammonia  in,  169 

in  dyspepsia,  182 
ammoniacal,    in    dyspepsia    of 
breast-fed  infant,  108 
intertrigo  from,  172 
casts  in,  218 
galactose  in,  42,  218 
hippiaric  acid  in,  40 
in  decomposition,  198 
in  intoxication,  21S 
in  normal  infant,  67 
in  pyloric  stenosis  and  pyloro- 

spasm,  282 
indican  in,  40 
lactose  in,  213,  218 
neutral  sulphur  in,  51 
nitrogen  in,  40 
phosphorus  in,  50 
saccharose  in,  42,  218 
UrobiUnogen  in  stool  in  diarrhea, 
241,  242 


Urobilinogen    in    stool    in   weight 

disturbance,  170,  171 
Usener,  78,  234 
Usuki,  42 

Van  Slyke,  119 
Veeder,  211 
Vegetable  soup,  134 

in  intoxication,  229 
Villi  of  intestines,  24 
VoegtUn,  271 
Vomiting,  236 

high  sugar-content  causing,  237 

in  dyspepsia,  181 

of  breast-fed  infant,  106 

in  intoxication,  216 

in  premature  infants,  248 

in  pyloric  stenosis  and  pyloro- 
spasm,  281 

in  weight  disturbance,  170 

malt  extract,  237 

milk-sugar,  237 

projectUe,  235,  238 
Vulvitis  in  exudative  diathesis,  255 

W.AXLS,  285 

Water,  retention  of,  43,  51 
in  eczema,  275 
in  sodium  metabolism,  48 
Weaning,  92,  93 

Weight,  action  of  calcium  on,  47 
body,  in  exudative  diathesis,  252 
curve  in  dj'spepsia  in  breast-fed 
infant,  109 
in  weight  disturbance,  171 
disturbance,  162,  168,  220 
acidosis  in  urine  in,  172 
ammonia-content  of  urine  in, 

172 
cane-sugar    in    treatment    of, 

175 
carbohydrates  in  treatment  of, 

175  ' 
constipation  in,  174 
convulsions  in,  173 
definition  of,  168 


314 


INDEX 


Weight  disturbance,  distention  of 

intestine  in,  171 
eczema  in    complications   in, 

174 
etiology  of,  168 
exudative  diathesis  in,  174 
fresh    air     in    treatment    of, 

177 
gastro-intestinal      symptoms, 

170 
in  breast-fed  infant,  97, 102 
lymph-glands  in,  172 
malt  extract  in  treatment  of, 

176 
malt-sugar   in   treatment   of, 

175,  176 
milk-sugar    in   treatment    of, 

175 
nasopharyngitis  in,  173 
nervous  symptoms  in,  173 
otitis  media  in,  173 
seborrhea  in,  177 
skin  in,  172 
soap  in  stools  in,  170 
starches  in  treatment  of,  175, 

176 
stewed  prunes  in,  177 
stool  in,  170 
suppositories  in,  177 
temperature  in,  173 
tissue-turgor  in,  172 


Weight  disturbance,   urobilinogen 
in  stool  in,  170,  171 
vomiting  in,  170 
weight  curve  in,  171 
gain  in,  from  administration  of 
sodium  chlorid  by  mouth,  48 
in  decomposition,  196 
in  dyspepsia,  183 
ia  undernourishment  of  breast- 
fed infant,  99 
initial  loss  of,  61 

in  intoxication,  214 
of  normal  infant,  60 
Wet-nursing,  94 
Wheat  flour  as  flour-ball,  134 

composition  and  caloric  value 
of,  133 
Wheat-gruel  flour,  134 
Whey,  caloric  value  of,  131 
composition  of,  127 
preparation  of,  127 
Whooping-cough,  gastric  lavage  in, 

288 
Wilcox,  131 
Winter  months,  decomposition  in, 

191 
Wolff,  192 
Wright,  47 

ZuCKERNAHRSCHADENj    157,    158 

ZybeU,  263 


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Dr.  M.  A.  Hann&,  University  MedUal  College,  Kansas  City 

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Dr.  Clark  E.  Day,  Indianapolis,  Ind 

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G  YXFJ '( '/. (u;V  A xn   (MIS TR T/x'/rs. 


Norris' 
Gonorrhea   in   Women 

Gonorrhea  in  Women.  By  Charles  C.  Norris,  M.  D.,  Instructor 
in  (jyncc()loi,fy,  University  of  Pennsylvania.  With  an  Introduction  by 
John  G.  Clark,  M.  D.,  Professor  of  Gynecolog>',  University  of  Penn- 
sylvania.    Large  octavo  of  520  pages,  illustrated.  Cloth,  36.00  net. 

A    CLASSIC 

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perium,  diffuse  gonorrheal  pertitonitis,  and  all  other  phases.  Furthur,  Dr.  Norris 
also  considers  the  rare  varieties  of  gonorrhea  occurring  in  men,  women,  and 
children.      The  text  is  illustrated. 

American  Text-Book  of  Gynecology 

Second    Revised    Edition 
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American  Text-Book  of  Obstetrics 

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Ashton's 
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The  Practice  of  Gynecology.  By  W.  Easterly  Ashton,  M.  D., 
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G yy ECOLOGY  AND    OBSrETRICS 


Bandler's 
Medical    Gynecology 


Medical  Gynecology.     V>y  S.  Wvllis    Banulek,    M.  D.,  Adjunct 
Professor  of  Diseases  of  Women,  New  York   Post-Graduate  Medical 
School  and   Hospital.     Octavo   of  790  pages,  with   150   original  illus- 
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tioner has  been  unable  to  treat  them  intelligently.  This  work  not  only  deals 
with  those  conditions  amenable  to  non-operative  treatment,  but  it  also  tells  how  to 
rcrognize  those  diseases  demanding  operative  treatment. 

American  Journal  of  Obstetrics 

'■  He  has  .shown  yuod  judgment  in  the  selection  of  his  data.  He  has  placed  most  emphasis 
on  diagnostic  and  therapeutic  aspects.  He  has  presented  his  facts  in  a  manner  to  be  readily 
grasped  by  the  general  practitioner." 


Bandler's  Vaginal   Celiotomy 

Vaginal  Celiotomy.  By  S.  Wvllis  Banulek,  M.  D.,  New  York 
Post-Graduate  INIedical  School  and  Hospital,  Octavo  of  450  pages,  with 
148  original  illustrations.     Cloth,  $5.00  net;  Half  Morocco,  $6.50  net. 

SUPERB  ILLUSTRATIONS 

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shock,  more  certain  results,  and  the  opportunity  for  conservative  measures,  con- 
stitutes a  field  which  should  appeal  to  all  surgeons,  gynecologists,  and  obstetricians. 
Posterior  vaginal  celiotomy  is  of  great  importance  in  the  removal  of  small  tubal 
and  ovarian  tumors  and  cysts,  and  is  an  important  step  in  the  performance  of 
vaginal  myomectomy,  hysterectomy,  and  hysteromyomectomy.  Anterior  vaginal 
celiotomy  with  thorough  separation  of  the  bladder  is  the  only  certain  method 
of  correcting  cystocele. 

The  Lancet,  London 

"  Dr.  liandler  has  done  good  service  in  writing  tliis  book,  which  gives  a  very  clear  descrip- 
tion of  all  the  operations  which  may  be  undertaken  through  the  vagina.  He  makes  out  a 
Strong  case  for  these  operations." 


SAUNDERS'    BOOKS    ON 


Kelly  and   Noble's 

Gynecology 

and  Abdominal  Surg^ery 

Gynecology  and  Abdominal  Surgery.  Edited  by  Howard  A. 
Kelly,  M.  D.,  Professor  of  Gynecology  in  Johns  Hopkins  University; 
and  Charles  P.  Noble,  M.  D.,  formerly  Clinical  Professor  of  Gyne- 
cology in  the  Woman's  Medical  College,  Philadelphia.  Two  imperial 
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TRANSLATED  INTO  SPANISH 
WITH   880   ILLUSTRATIONS    BY  HERMANN  BECKER  AND   MAX   BRODEL 

In  view  of  the  intimate  association  of  gynecology'  with  abdominal  surgen'  the 
editors  have  combined  these  two  important  subjects  in  one  work.  For  this  reason 
the  work  \vill  be  doubly  valuable,  for  not  only  the  gynecologist  and  general  prac- 
titioner will  find  it  an  exhaustive  treatise,  but  the  surgeon  also  will  find  here  the 
latest  technic  of  the  various  abdominal  operations.  It  possesses  a  number  of 
valuable  features  not  to  be  found  in  any  other  publication  covering  the  same  fields. 
It  contains  a  chapter  upon  the  bacteriology  and  one  upon  the  pathology  of  gyne- 
colog}^  dealing  fully  with  the  scientific  basis  of  gynecology.  In  no  other  work 
can  this  information,  prepared  by  specialists,  be  found  as  separate  chapters. 
There  is  a  large  chapter  devoted  entirely  to  medical  gyfiecology  written  especially 
for  the  physician  engaged  in  general  practice.  Heretofore  the  general  practitioner 
was  compelled  to  search  through  an  entire  work  in  order  to  obtain  the  information 
desired.  Abdo77iinal  surgery  proper,  as  distinct  from  gynecolog}^  is  fully  treated, 
embracing  operations  upon  the  stomach,  upon  the  intestines,  upon  the  liver  and 
bile-ducts,  upon  the  pancreas  and  spleen,  upon  the  kidneys,  ureter,  bladder,  and 
the  peritoneum.  The  illustrations  are  truly  magnificent,  being  the  work  of  Mr. 
Hennann  Becker  and  Mr.  Max  Brodel. 

Americsui  Journal  of  the  Medical  Sciences 

"  It  is  needless  to  say  that  the  work  has  been  thoroughly  done :  the  names  of  the  authors 
and  editors  would  guarantee  this  ;  but  much  may  be  said  in  praise  of  the  method  of  presen- 
tation, and  attention  may  be  called  to  the  inclusion  of  matter  not  to  be  found  elsewhere." 


G  VNECOLOG  V  AND  OBSTE TRIGS 


Webster's 
Text-Book  qf  Obstetrics 

A  Text-Book  of  Obstetrics.  \\\  J.  Claki.nce  Webster,  M.  D. 
(Edin.),  F.  R.  C.  P.  K..  Professor  of  Obstetrics  and  Gynecology  in  Rush 
Medical  College,  in  affiliation  with  the  University  of  Chicago.  Octavo 
volume  of  767  pages,  illustrated.  Cloth,  $5.00  net;  Half  Morocco, 
^6.50  net. 

BEAUTIFULLY     ILLUSTRATED 

In  this  work  the  anatomic  changes  accompanying  pregnancy,  labor,  and  the 
puerperium  are  described  more  fully  and  lucidly  than  in  any  other  text-book  on 
the  subject.  The  exposition  of  these  sections  is  based  mainly  upon  studies  of 
frozen  specimens.  Unusual  consideration  is  given  to  embryologic  and  physiologic 
data  of  im])ortance  in  their  relation  to  obstetrics. 

Buffalo  Medical  Journal 

"  As  a  practical  text-book  on  obstetrics  for  both  student  and  practitioner,  there  is  left  very 
little  to  be  desired,  it  being  as  near  perfection  as  any  compact  work  that  has  been  published." 


Webster's 
Diseases   of  Women 

A  Text-Book  of  Diseases  of  Women.  By  J.  Clarence  Webster, 
M.  D.  (Edin.),  Y.  R.  C.  P.  E.,  Professor  of  Gynecology  and  Obstetrics 
in  Rush  Medical  College.  Octavo  of  712  pages,  with  372  text-illustra- 
tions and  10  colored  plates.     Cloth,  $7.00  net ;  Half  Morocco,  $8.50  net. 

Dr.  Webster  has  written  this  work  especially  for  the  general  practitioner,  dis- 
cussing the  clinical  features  of  the  subject  in  their  widest  relations  to  general 
practice  rather  than  from  the  standpoint  of  specialism.  The  magnificent  illus- 
trations, three  hundred  and  seventy-two  in  number,  arc  nearly  all  original. 

Howard  A.  Kelly    M.  D. 

Professor  of  Civnecologic  Surgery,  fohns  Hopkins  University. 

"  It  is  undoubtedly  one  of  the  best  works  which  has  been  put  on  the  market  within  recent 
years,  showing  from  start  to  finish  Dr.  Webster's  well-known  thoroughness.  The  illustrations 
are  also  of  the  highest  order.  " 


SAUNDERS'   BOOKS   ON 


Hirst's 
Text-Book  of  Obstetrics 

The  New  (7th)  Edition 


A  Text=Book  of  Obstetrics.  By  Barton  Cooke  Hirst,  M.  D., 
Professor  of  Obstetrics  in  the  Universitj^  of  Pennsylvania.  Handsome 
octavo  of  1013  pages,  witii  895  illustrations,  53  of  them  in  colors. 
Cloth,  ;^5.oo  net ;  Half  Morocco,  $6.50  net. 

INCLUDING  RELATED  GYNECOLOGIC  OPERATIONS 

Immediately  on  its  publication  this  work  took  its  place  as  the  leading  text-book 
on  the  subject.  Both  in  this  country  and  in  England  it  is  recognized  as  the  most 
satisfactorily  written  and  clearly  illustrated  work  on  obstetrics  in  the  language. 
The  illustrations  form  one  of  the  features  of  the  book.  They  are  numerous  and 
the  most  of  them  are  original.  In  this  edition  the  book  has  been  thoroughly  revised. 
Recognizing  the  inseparable  relation  between  obstetrics  and  certain  gynecologic 
conditions,  the  author  has  included  all  the  gynecologic  operations  for  complica- 
tions and  consequences  of  childbirth,  together  with  a  brief  account  of  the  diagnosis 
and  treatment  of  all  the  pathologic  phenomena  peculiar  to  women. 


OPINIONS  OF  THE  MEDICAL  PRESS 


British  Medical  Journal 

"  The  popularity  of  American  text-books  in  this  country  is  one  of  the  features  of  recent 
years.  The  popularity  is  probably  chiefly  due  to  the  great  superiority  of  their  illustrations 
over  those  of  the  English  text-books.  The  illustrations  in  Dr.  Hirst's  volume  are  far  more 
numerous  and  far  better  executed,  and  therefore  more  instructive,  than  those  commonly 
found  in  the  works  of  writers  on  obstetrics  in  our  own  country." 

Bulletin  of  Johns  Hopkins  Hospited 

"The  work  is  an  admirable  one  in  every  sense  of  the  word,  concisely  but  comprehensively 
written." 

The  Medical  Record,  New  York 

"  The  illustrations  are  numerous  and  are  works  of  art,  many  of  them  appearing  for  the  first 
time.  The  author's  style,  though  condensed,  is  singularly  clear,  so  that  it  is  never  necessary 
to  re-read  a  sentence  in  order  to  grasp  the  meaning.  As  a  true  model  of  what  a  modern  text- 
book on  obstetrics  should  be,  we  feel  justified  in  affirming  that  Dr.  Hirst's  book  is  without  a 
rival." 


DISEASES   OF    WOMEN. 


HirstV 
Diseases  of  Women 


A  Text-Book  of  Diseases  of  Women.  By  Hakton  Cookk  Hirst, 
M.  D.,  Professor  of  Obstetrics,  University  of  Pennsylvania  ;  Gynecolo- 
gist to  the  Moward,  the  Orthopedic,  and  the  Philadelphia  Hospitals. 
Octavo  of  745  pages,  with  701  original  illustrations,  many  in  colors. 
Cloth,  $5.00  net;  Half  Morocco,  $6.50  net. 

THE    NEW   (2d)    EDITION 
WITH    701    ORIGINAL    ILLUSTRATIONS 

The  new  edition  of  this  work  has  just  been  issued  after  a  careful  revision. 
As  diagnosis  and  treatment  are  of  the  greatest  importance  in  considering  diseases 
of  women,  particular  attention  has  been  devoted  to  these  divisions.  To  this  end, 
also,  the  work  has  been  magnificently  illuminated  with  701  illustrations,  for  the 
most  part  original  photographs  and  water-colors  of  actual  cHnical  cases  accumu- 
lated during  the  past  fifteen  years.  The  palliative  treatment,  as  well  as  the 
radical  operative,  is  fully  described,  enabling  the  general  practitioner  to  treat 
many  of  his  own  patients  v  ithout  referring  them  to  a  speciaHst.  An  entire  sec- 
tion is  devoted  to  '.  full  description  of  all  modern  gynecologic  operations,  illumi- 
nated and  elucidated  by  numerous  photographs.  The  author's  e.xtensive  ex- 
perience renders  ^nis  work  of  unusual  value. 


OPINIONS  OF  THE  MEDICAL  PRESS 


Medical  Record,  New  York 

"Its  merits  can  be  appreciated  only  by  a  careful  perusal.  .  .  .  Nearly  one  hundred  pages 
are  devoted  to  technic,  this  chapter  being  in  some  respects  superior  to  the  descriptions  in 
many  other  text-  boks." 

Boston  Medical  and  Surgical  Journal 

'  Tiio  .uithor  has  given  special  attention  to  diagnosis  and  treatment  throtighout  the  book, 
and  has  produced  a  practical  treatise  which  should  be  of  the  greatest  value  to  the  student,  the 
general  practitioner,  and  the  specialist." 

Medical  News,  New  York 

"  Oflfice  treatment  is  given  a  due  amount  of  consideration,  so  that  the  work  will  be  as 
useful  to  the  non-operator  as  to  the  specialist." 


SAUNDERS'    BOOKS   ON 


GET  ^  •  THE  NEW 

THE  BEST  /\  IH  ©  r  1  C  8i  H  STANDARD 

Illustrated   Dictionary 

New  (7th)  Edition— 5000  Sold  in  Two  Months 


The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistry,  Veterinary  Science,  Nursing,  and  kindred 
branches  ;  with  over  lOO  new  and  elaborate  tables  and  many  handsome 
illustrations.  By  W.  A.  Newman  Borland,  M.D.,  Editor  of  "The 
American  Pocket  Medical  Dictionary."  Large  octavo,  1107  pages, 
bound  in  full  flexible  leather.  Price,  $^^.^0  net;  with  thumb  index, 
$5.00  net. 

IT  DEFINES  ALL  THE  NEW  WORDS— MANY  NEW  FEATURES 

The  American  Illustrated  Medical  Dictionary  defines  hundreds  of  the  newest 
terms  not  defined  in  any  other  dictionary — bar  none.  These  new  terms  are  live, 
active  words,  taken  right  from  modern  medical  literature. 

It  gives  the  capitalization  and  pronunciation  of  all  words.  It  makes  a  feature 
of  the  derivation  or  etymology  of  the  words.  In  some  dictionaries  the  etymology 
occupies  only  a  secondary  place,  in  many  cases  no  derivation  being  given  at  all. 

In  the  '  'American  Illustrated  ' '  practically  every  word  is  given  its  derivation. 

Every  word  has  a  separate  paragraph,  thus  making  it  easy  to  find  a  word 
quickly. 

The  tables  of  arteries,  muscles,  nerves,  veins,  etc.,  are  of  the  greatest  help 
in  assembling  anatomic  facts.  In  them  are  classified  for  quick  study  all  the 
necessary  information  about  the  various  structures. 

Every  word  is  given  its  definition — a  definition  that  defines  in  the  fewest  pos- 
sible words.  In  some  dictionaries  hundreds  of  words  are  not  defined  at  all,  refer- 
ring the  reader  to  some  other  source  for  the  information  he  wants  at  once. 

Howard  A.  Kelly,  M.  Ti.,  Johns  Hopkins  University,  Bailiniore 

"  The  American  Illustrated  Dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such 
convenient  size.     No  errors  have  been  found  in  my  use  of  it." 

J.  Collins  Warren,  M.  D.,  LL.D.,  F.R.C.S.  (Hon.),  Harvard  Medical  School 

"  I  regard  it  as  a  valuable  aid  to  my  medical  literary  work.  It  is  very  complete  and  o( 
convenient  size  to  handle  comfortably,     I  use  it  in  preference  to  any  other." 


GYNECOLOGY  AM)    OBSTETRICS  l\ 

Penrose's 
Diseases  of  Women 

Sixth    Revised    Edition 


A  Text-Book  of  Diseases  of  Women.  By  Charles  B.  Penrose, 
M.  D.,  Ph.  D.,  formerly  Professor  of  G>'necology  in  the  University  of 
Penns>'lvania  ;  Surgeon  to  the  Gynecean  Hospital,  Philadelphia,  Oc- 
tavo volume  of  550  pages,  with  225  fine  original  illustrations.     Cloth, 

S3.75   net. 

ILLUSTRATED 

Regularly  every  year  a  new  edition  of  this  excellent  text-book  is  called  for, 
and  it  appears  to  be  in  as  great  favor  with  physicians  as  with  students.  Indeed, 
this  book  has  taken  its  place  as  the  ideal  work  for  the  general  practitioner.  The 
author  presents  the  best  teaching  of  modern  gynecology,  untrammeled  by  anti- 
quated ideas  and  methods.  In  every  case  the  most  modern  and  progressive 
technique  is  adopted  and  made  clear  by  excellent  illustrations. 

Howard  A.  Kelly.  M.D.. 

Professor  of  Gyttecologic  Surgery,  Johns  Hopkins  University,  Baltimore. 

"  I  shall  value  very  highly  the  copy  of  Penrose's  '  Diseases  ofWomen'  received.  I  liave 
already  recommended  it  to  my  class  as  THE  HEST  book." 


Davis*  Operative  Obstetrics 

Operative  Obstetrics.  By  Edward  P.  D.vyis,  M.D.,  Professor  of 
Obstetrics  at  Jefferson  Medical  College,  Philadelphia.  Octavo  of  483 
pages,  with  264  illustrations.     Cloth,  $5.50 net;  Half  Morocco,  $7.00  net. 

INCLUDING  SURGERY  OF  NEWBORN 

Dr.  Davis'  new  work  is  a  most  practical  one,  and  no  expense  has  been  spared 
to  make  it  the  handsomest  work  on  the  subject  as  well.  Ever)'  step  in  everj' 
operation  is  described  minutely,  and  the  technic  shown  by  beautiful  new  illustra- 
tions.    Dr.  Davis'  name  is  sufficient  guarantee  for  something  above  the  mediocre. 


^2  SAUNDERS'    BOOKS   ON 

Dorland's 
Modern   Obstetric»r 


Modern  Obstetrics :  General  and  Operative.     By  W.  A.  Newman 

DoRLAND,  A.  M.,  M.  D.,  Professor  of  Obstetrics  at  Loyola  University, 
Chicago,  Illinois.  Handsome  octavo  volume  of  797  pages,  with  201 
illustrations.     Cloth,  ^4.00  net. 

Second  Edition,  Revised  and  Greatly  Enlarged 

In  this  edition  the  book  has  been  entirely  rewritten  and  very  greatly  enlarged. 
Among  the  new  subjects  introduced  are  the  surgical  treatment  of  puerperal  sepsis, 
infant  mortality,  placental  transmission  of  diseases,  serum-therapy  of  puerperal 
sepsis,  etc.  By  new  illustrations  the  text  has  been  elucidated,  and  the  subject  pre- 
sented in  a  most  instructive  and  acceptable  form. 

Jotimal  of  the  American  MediceJ  Association 

"  This  work  deserves  commendation,  and  that  it  has  received  what  it  deserves  at  the  hands 
of  the  profession  is  attested  by  the  fact  that  a  second  edition  is  called  for  within  such  a  short 
time.     Especially  deserving  of  praise  is  the  chapter  on  puerperal  sepsis." 

Davis*  Obstetric  and 
Gynecologic  Nursing 

Obstetric  and  Gynecologic  Nursing.  By  Edward  P.  Davis,  A.  M., 
M.  D.,  Professor  of  Obstetrics  in  the  Jefferson  Medical  College  and 
Philadelphia  Polyclinic ;  Obstetrician  and  Gynecologist,  Philadelphia 
Hospital.      i2mo  of  480  pages,  illustrated.     Buckram,  $1.75  net, 

NEW  (4th)  EDITION 

Obstetric  nursing  demands  some  knowledge  of  natural  pregnancy,  and  gyne- 
cologic nursing,  really  a  branch  of  surgical  nursing,  requires  special  instruction 
and  training.  This  volume  presents  this  information  in  the  most  convenient 
form.  This  third  edition  has  been  very  carefully  revised  throughout,  bringing  the 
subject  down  to  date. 

The  Lancet,  London 

"  Not  only  nurses,  but  even  newly  qualified  medical  men,  would  learn  a  great  deal  by  a 
perusal  of  this  book.  It  is  written  in  a  clear  and  pleasant  style,  and  is  a  work  we  can  recom- 
mend." 


GYNECOLOGY  AND    OBSTETRICS.  13 

Kelly  and  Cullen's 
Myomata   of  the  Uterus 


Myomataof  the  Uterus.     \\y  Howard  A.  Kellv,  M.  D.,  Professor 

of  GynccoloLjic  Surgery  at  Johns  Hopkins  Universit)';  and  Thomas  S. 
CuLLKN,  M.  B.,  .Associate  in  Gynecology  at  Johns  Hopkins  University. 
Large  octavo  of  about  700  pages,  with  388  original  illustrations,  by 
August  Horn  and  Hermann  Becker.  Cloth,  $7.50  net ;  Half  Morocco, 
■  $9.00  net. 

ILLUSTRATED     BY     AUGUST     HORN     AND     HERMANN     BECKER 

This  monumental  work,  the  fruit  of  over  ten  years  of  untiring  labors,  will 
remain  for  many  years  the  last  word  upon  the  subject.  Written  by  those  men 
who  have  brought,  step  by  step,  the  operative  treatment  of  uterine  myoma  to 
such  perfection  that  the  mortality  is  now  less  than  one  per  cent.,  it  stands  out  as 
the  record  of  greatest  achievement  of  recent  times. 

Surgery,  Gynecology,  and  Obstetrics 

••  It  must  lie  consiilered  as  the  most  comprtheiisive  work  of  the  kind  yet  published.  It 
will  always  be  a  mine  of  wealth  to  future  students." 


Cullen*s  Adenomyoma  of  the  Uterus 

AijE.numvoma  oi-  I  UK  Utkrls.  By  'rH(<MAs  S.  CuLLiiN,  M.B.  Octavo  of  275 
pages,  with  orij^inal  illustrations  by  Hermann  Becker  and  August  Horn.  Clotii, 
$5.00  net;   Half  .Moiocco,  td.^O  net. 

"A  good  example  of  how  such  a  monograph  should  be  writien.  Tt  is  an  excellent 
work,  worthy  of  the  high  reputation  of  the  author  and  of  the  school  from  wiiich  it 
emanates." — The  Lancet,  London. 

Cullen's  Cancer  of  the  Uterus 

Cancer  of  thk  Uterus.  By  Thomas  S.  Cullen,  M.B.  Large  octavo  of  693 
pages,  with  over  300  colored  and  half-tone  text-cuts  and  eleven  lithographs.  Cloth, 
J7.50  net  ;  Half  Morocco,  $8.50  net. 

"  Dr.  Cullen's  book  is  tlie  standard  work  on  the  greatest  problem  which  faces  the 
surgical  worhl  to-day.  Any  one  who  desires  to  attack  this  great  problem  must  have 
this  book." — Howard  A.  Kkilv.  M.  D.,  Johns  Llopkins  Cniversity. 


14  SAUNDERS'    BOOKS    ON 

Schaffer  and  Edgar' :f  Labor  and  Operative  Obstetrics 

Atlas  and    Epitome  of    Labor    and    Operative    Obstetrics.      By    Dr. 

O.  ScHAFFER,  of  Heidelberg.  Edited,  with  additions,  by  J.  Clifton  Edgar, 
i\I.  D.,  Professor  of  Obstetrics  and  Clinical  Midwifer)-,  Cornell  University 
Medical  School,  New  York.  With  14  lithographic  plates  in  colors,  139  text- 
cuts,  and  III  pages  of  text.      Cloth,  52. 00  net.     In  Saimders'  Hand- Atlases. 


Schaffer     and     Edgar's     Obstetric     Diagnosis     and 
Treatment 

Atlas  and  Epitome  of  Obstetric  Diagnosis  and   Treatment.     By  Dr. 

O.  Schaffer,  of  Heidelberg.  Edited,  with  additions,  by  J.  Clifton  Edgar, 
jM.  D.,  Professor  of  Obstetrics  and  Clinical  Mid\vifer\-,  Cornell  University 
IMedical  School,  Xew  York.  ^Vith  122  colored  figures  on  56  plates,  38  text- 
cuts,  and  315   pages  of  text.      Cloth,    S3. 00  net.      Satmders'  Hand-Atlases. 


Schaffer  and  Norris*  Gynecology 

Atlas  and  Epitome  of  Gynecology.  By  Dr.  O.  Schaffer,  of  Heidel- 
berg. Edited,  with  additions,  by  Richard  C.  Norris,  A.  M. ,  M.  D., 
Gynecologist  to  Methodist  Episcopal  and  Philadelphia  Hospitals.  ^Vith  207 
colored  figures  on  90  plates,    65  text-cuts,  and  308  pages  of  text.     Cloth, 

S3.  50  net.      hi  Saunders''  Hand-Atlas  Series. 


Galbraith's  Four  Epochs  of  Woman's   Life 

New  (2d)  Edition 

The  Four  Epochs  of  Woman's  Life :  A  Study  in  Hygiene.  By  Anna 
^l.  Galbraith,  M.  D.,  Fellow  of  the  New  York  Academy  of  Medicine,  etc. 
\Vith  an  Introductor}'  Note  by  John  H.  Musser,  M.  D.,  Universit-y  of 
Pennsylvania.      i2mo  of  247  pages.      Cloth,  si.50  net. 

Birmingham  Medical  Review,  Engleoid 

"  AVe  do  not,  as  a  ru'e,  care  for  medical  books  written  for  the  instruction  of  the  public. 
But  we  must  admit  that  the  advice  in  Dr.  Galbraith's  work  is,  in  the  main,  wise  and 
wholesome." 


Garrigues'  Diseases  of  Women  Third  Edition 

A  Text=Book  of  Diseases  of  Women.  By  Henry  J.  Garrigues,  M.  D., 
Gynecologist  to  St.  Mark's  Hospital,  New  York  City.  Octavo  of  756  pages, 
illustrated.      Cloth,  $4. 50  net ;   Half  :\Iorocco,  s6.oo  net. 


f;  )'/VAv  o/.tx;  r  .-iv/)  onsri:  irk  s. 

Schaffer  and  Webster's 
Operative  Gynecology 


Atlas  and  Epitome  of  Operative  Gynecology,  By  Dk.  O.  Schaf- 
fer, of  I  Icidelbcr<^.  I'^ditcd,  with  additions,  by  J.  Clakenck  Webster, 
M.D.  (Edin.),  F.R.C.P.E.,  Professor  of  Obstetrics  and  Gynecology  in 
Rush  Medical  College,  in  affiliation  with  the  University  of  Chicago. 
42  colored  lithographic  plates,  many  text-cuts,  a  number  in  colors,  and 
138  pages  of  text.     ///  Saunders'  Hand-Atlas  Scries.    Cloth,  $3.00  net. 


Much  patient  endeavor  has  been  expended  by  the  author,  the  artist,  and  the 
lithographer  in  the  preparation  of  the  plates  of  this  atlas.  They  are  based  on 
hundreds  of  photographs  taken  from  nature,  and  illustrate  most  faithfully  the 
various  surgical  situations.  Dr.  Schaffer  has  made  a  specialty  of  demonstrating 
by  illustrations. 

Medical  Record,  New  York 

"  The  volume  should  prove  most  Helpful  to  students  and  others  in  grasping  details  usually 
to  be  acquired  only  in  the  amphitheater  itself." 

De  Lee's 
Obstetrics  for  Nurses 


Obstetrics  for  Nurses.     By  Joseph  B.  De  Lee,  M.D.,  Professor  of 

Obstetrics  in  the  Northwestern  University  Medical  School ;  Lecturer 
in  the  Nurses'  Training  Schools  of  Mercy,  Wesley,  Provident,  Cook 
County,  and  Chicago  Lying-in  Hospitals.  i2mo  \olume  of  508  pages, 
fully  illustrated.  Cloth,  52.50  net. 

THE  NEW  i4th)  EDITION 

While  Dr.  De  Lee  has  written  his  work  especially  for  nurses,  yet  the  prac- 
titioner will  find  it  useful  and  instructive,  since  the  duties  of  a  nurse  often  devolve 
upon  him  in  the  early  years  of  his  practice.  The  illustrations  are  nearly  all 
original,  and  represent  photographs  taken  from  actual  scenes.  The  text  is  the 
result  of  the  author's  many  years'  experience  in  lecturing  to  the  nurses  of  five 
different  training  schools. 

J.  Clifton  Edgar.  M.  D., 

Professor  0/  Obstitrics  and  Clinical  Midwifery,  Cornell  University .  New  York. 
"  It  is  far  and  away  the  best  that  has  come  to  my  notice,  and  I  shall  take  great  pleasure  in 
recommending  it  to  my  nurses,  and  students  as  well." 


i6      SAUXDERS-  BOOKS  OX  GYNECOLOGY  AND   OBSTETRICS. 

American  Pocket  Dictionary  New  (Sthj  Edition 

The  American  Pocket  Medical  Dictionary.  Edited  by  W. 
A.  Newman  Dorland,  A.  ^I.,  ^I.  D.  677  pages.  |i.oo  net;  with 
patent  thumb  index,  $1.25  net. 

James  W.  Holland,  M.D.. 

Professor   of  Medical    Chemistry    and    Toxicology    at  the  Jefferson   Medical    College^ 
Philadelphia. 

"  I  am  struck  at  once  with  admiration  at  the  compact  size  and  attractive  exterior.  J 
can  recommend  it  to  our  students  %v'ithout  reserve." 

Cragin's  Gynecolo^.  New^rth)  EdMon 

Essentials  of  Gynecology.  By  Edwin  B.  Cragin,  ]\I.  D., 
Professor  of  Obstetrics,  College  of  Physicians  and  Surgeons,  New 
York.  Crown  octavo,  232  pages,  59  illustrations.  Cloth,  ^i.oo 
net.     In  Saunders'   Question- Compend  Series. 

The  MedicEd  Record,  New  York 

"A  handy  volume  and  a  distinct  improvement  ot  students'  compends  in  general. 
Xo  author  who  was  not  himself  a  practical  gynecologist  could  have  consulted  the 
student's  needs  so  thoroughly  as  Dr.  Cragin  has  done." 

Ashton*s  Obstetrics.  New  (7th)  Edition 

E.SSENTIALS    OF    OBSTETRICS.       By  W.  EASTERLY  ASHTON,  M.  D., 

Professor  of  Gynecology  in  the  Medico-Chirurgical  College,  Phila- 
delptiia.  Revised  by  John  A.  McGlinn,  M.  D.,  Assistant  Professor 
of  Obstetrics  in  the  Medico-Chirurgical  College  of  Philadelphia. 
l2mo  of  287  pages,  109  illustrations.  Cloth,  31.00  net.  In  Saunders^ 
Question-  Conipeiid  Series. 

Southern  Practitioner 

"  An  excellent  little  volume  ccjtaining  correct  and  practical  knowledge.  An  admir- 
able compend.  and  the  best  condensation  we  have  seen." 

Barton  and  Wells'  Medical  Thesaurus 

A  Thesaurus  of  ]\Iedical  Words  and  Phrases.  By  Wilfred 
M.  Barton,  M.  D.,  Assistant  to  Professor  of  Materia  ]\Iedica  and 
Therapeutics,  Georgetown  University,  Washington,  D.  C. ;  and 
Walter  A,  Wells,  M.  D.,  Demonstrator  of  Lar^mgology,  George- 
town University',  Washington,  D.  C.  i2mo  of  534  pages.  Flex- 
ible leather,  $2.50  net;  with  thumb  index,  33.00  net. 

Macfarlane's   Gynecolog(y  for  Nurses  second  Edition 

A  Reference  Hand-Book  of  Gynecology  for  Nurses.  By  Cath- 
arine ]\La.cfarlane,  Isi.  D.,  Gynecologist  to  the  AVoman's  Hospital  of 
Philadelphia.  32mo  of  150  pages,  with  70  illustrations.  Flexible 
leather,  51-25  net. 

A.  M.  Seabrook,  M.  D., 

Woman's  Medical  College  of  Philadelphia. 

"  It  is  a  most  admirable  little  book,  covering  in  a  concise  but  attractive  way  the  subject 
from  the  nurse's  standpoint." 


Gruiee. 


